PACE UNIVERSITY ATHLETES

"KIDS NIGHT OUT”

Consent, Waiver, and Release

TO: Pace University Athletics-KNO

861 Bedford Road
Pleasantville, NY 10570

Name of Child (Please Print):

Address:

In consideration of the above named student being permitted to participate in the Pace University’s “Kids Night Out” Program, the undersigned does hereby agree to assume all the risks and responsibilities surrounding such participation or any activities undertaken as an adjunct thereto; and further, for myself, my heirs and personal representatives, I hereby agree to defend, hold harmless, indemnify and release forever, and forever discharge Pace and all its officers, agents and employees from and against any and all claims, demands and actions or causes of action, on account of damage to personal property, or personal injury, or death which may result from the aforesaid participation and activities incident thereto. It is hereby certified that the above-named child has no medical or psychological conditions which would preclude such participation, and I authorize Pace through its authorized agents to secure for the child any necessary emergency medical treatment.

____________ _______________________________________
Date (Parent/Guardian)

Name and phone number to call in case of Emergency.

___________________________________ __________________ _______________
Name Telephone-Work Telephone-Home

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PACE UNIVERSITY ATHLETES

"KIDS NIGHT OUT”

Consent, Waiver, and Release

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