Multicultural Programs

Future Nurses Day Registration

November 16, 2013

8:45am - 12:15pm

Linfield College – Portland
2255 NW Northrup St.
Portland, OR 97210

Student & Family Registration Form

*Required Fields

*Name: *Address (Street, City, State, Zip): Phone Number: *Email (required):

I will be attending as a high school student I will be attending as a college transfer student I will be attending as a college graduate (accelerated BSN for post-grad students)

School Currently Attending: Expected Graduation Date: Career Goal(s):

Will Your Family Attend the Program?

Yes No

*Number of Adults (Including yourself): *Number of Children: Ages of Children: Please list any special dietary needs

Registration Deadlines
November 8, 2013

RELEASE AND ASSUMPTION OF RISK

*Your name and those of your guests separating names with commas Date

I am aware that participation in this event involves certain risks. Knowing of such inherent risks, and in consideration of the right to participate in the event, I represent and agree as follows:

1) I assume all risks associated with the event. I agree that I will not make any claim or sue for injuries which may arise out of my participation in the event, including injury or damage which may result from the acts -- negligent or otherwise -- of Linfield College, or any agent, employee, or contractor of Linfield College.

2) I release and agree to hold harmless Linfield College, its agents, employees and contractors, from liability, claims and causes of action for injury or damage, which I may suffer or incur, arising out of my participation in the event.

3) In addition to the foregoing, I grant to Linfield College the full authority to take whatever action they feel is necessary and warranted and to arrange for medical transportation, aid, treatment and hospitalization in order to protect my health safety and welfare, and I agree to bound by any and all conditions and regulations relating to the event.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS, AND I SIGN IT OF MY OWN FREE WILL. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY FOR NEGLIGENCE AND A HOLD HARMLESS AGREEMENT, AND IS A BINDING CONTRACT BETWEEN LINFIELD COLLEGE AND MYSELF, and it likewise shall be binding on my heirs, executors, administrators, and assigns.

*I understand that typing my name will serve as my signature to this agreement for me and my guests listed above. *Please sign Date

Parental/Guardian Signature (if person listed above is under 18 years of age)

Please sign Date

Registration Deadlines
November 8, 2013

MODEL RELEASE

I do hereby give LINFIELD COLLEGE, their assigns, licensees, and legal representatives the irrevocable right to use my name, personal quotations, picture, portrait, or photograph in all forms and media and in all manners, including composite or altered representations, for communications, publications, or any other lawful purposes, and I waive any right to inspect or approve the finished version(s), including written copy or web site that may be created in connection therewith. I have read this release and am fully familiar with its contents.

I understand that typing my name will serve as my signature to this agreement for me and my guests listed above.

Please check

Signature : Address : Phone # : E-Mail : Date :

Registration Deadlines
November 8, 2013

For more information please contact Michael Reyes Andrillon
(503) 413-7273
mreyesa@linfield.edu

Registrants will receive a registration confirmation packet via email that includes driving and parking directions.