Waiver - Overnights

WAIVER OF LIABILITY / PERMISSION / MEDICAL RELEASE FORM

This form is required for any student staying overnight in a Mount Holyoke College residence hall. This waiver must by completed by both the student and parent or guardian and submitted prior to the start of your overnight stay.

Please read Waiver of Liability and sign. A copy of this waiver will be sent to the parent or guardian you designate in the required field. This form is not considered complete until both student and parent or guardian have consented.

I hereby release, indemnify and hold harmless Mount Holyoke College, including Mount Holyoke College, its trustees, employees, volunteer workers, students, agents and assigns from any and all liability, damage, claim of any nature whatsoever arising out of or in any way related to my/my child’s participating including any and all travel risks in this visit to Mount Holyoke. Participating in any activity is an acceptance of some risk of injury. I agree that my/my child’s safety is primarily dependent upon my/my child’s taking proper care of myself/my child’s self. Despite precautions, accidents and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participation in this visit. Therefore, I assume all risks related to the activities. In case of an emergency and if my parent/we cannot be reached, I do hereby authorize a representative of Mount Holyoke College to consent to any medical treatment or care deemed advisable.

My electronic signature below indicates that I have read, understood and freely consented to this agreement, which shall take effect as a sealed instrument. I expressly agree that this agreement shall be construed and enforced in accordance with Massachusetts laws, and I consent to the jurisdiction of said state. I agree that this waiver and release is intended to be as broad and inclusive as permitted under Massachusetts laws so that if any portion hereof is held invalid, the balance shall continue in full legal force and effect.

STATEMENT OF STUDENT RESPONSIBILITY

We are very pleased that you plan to stay overnight at Mount Holyoke College. This is an excellent opportunity for you to explore daily life at the College. We ask that all overnight visitors agree to the following statements:

While on campus, I will be held to the same standards and code of conduct as an enrolled student, and I will assume sole responsibility for my own actions.
I am aware that although Mount Holyoke College has agreed to host me overnight, neither the Office of Admission nor any other office or personnel of Mount Holyoke College will be supervising me at all times during my stay on campus.
I am aware that participants in on-campus visitation programs are required to abide by Massachusetts state law, and I agree to do so. I acknowledge that Massachusetts’ law prohibits all use of illegal drugs and prohibits the drinking of alcoholic beverage by persons under 21 years of age.

By checking this box, I agree to the term and conditions of the Waiver of Liability and Statement of Student Responsibility*

Student First Name*

Last Name*

Email Address*

Birthdate*

Emergency Contact Information & Consent

The information provided below will be used to obtain consent form your parent or guardian. Please make sure the information you provide is accurate.

Parent / Guardian First Name*

Parent / Guardian Last Name*

Parent / Guardian Email*

Parent / Guardian Cell #*

Relationship to Student*

Parent / Guardian Consent

By checking this box, I agree to the term and conditions of the Waiver of Liability and Statement of Student Responsibility*

Waiver - Overnights

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