I, the undersigned Parent/Guardian of ("the
student"), ________________________
Printed Name of the Student
__________________________ Date of
Birth _______________________________ Address
_________________ Social Security Number
(optional) _______________________ City, State,
Zip Code
understand and hereby consent and agree as follows:
The student has been offered the opportunity to work at the University of
Maryland, Baltimore under the supervision of:
___________________________ Supervisor
Name ____________________________ Department/School
I understand that laboratories are potentially hazardous environments
involving the use of scientific instruments, chemicals, radioactive
materials and biological materials. Even under ideal laboratory
conditions, proper use of these materials results in risk of
personal injury, and improper use of these materials involves
even greater risk. I understand that laboratory personnel have
the right to exclude the student from activities believed to
be inherently dangerous or inappropriate for the experience
level of the student. Also, I understand and agree that the
student may be removed from the laboratory on a temporary or
permanent basis due to failure or inability to follow laboratory
rules and perform laboratory work as directed. My child will
receive appropriate training on how to identify these hazards
and work with them safely. My child will be supervised in handling
of such instrumentation and materials.
I grant my permission to the University of Maryland, Baltimore,
its physicians, members of its faculty, agents, servants, and
employees to provide such emergency care and treatment to the
student, as in their judgment may be deemed necessary or advisable
in the event that the student should require emergency care
while acting in the course of his/her work at the University.
I assume the cost of such emergency care and treatment, if any.
In consideration of the student’s opportunity to participate
in the laboratory program, I hereby indemnify, release, and
hold harmless the State of Maryland, the University of Maryland,
Baltimore, and the faculty, employees and agents of the University
of Maryland, Baltimore, from any and all claims, liabilities,
suits, and damages relating to or arising from the student’s
experience at University of Maryland, Baltimore, saving and
excepting only claims allowed by the Maryland state tort claims
act or other applicable statute permitting claims against the
state of Maryland.
PARENT/GUARDIAN: __________________________________
Signature and Date
__________________________ Printed
Name _______________________________ Address
______________________________________ City, State, Zip Code
WITNESS: _______________________________________ Signature
and Date
_______________________________ Printed
Name __________________________ Address
_______________________________________ City, State, Zip Code
