Hiring Minors: Forms

I hereby assume all risks relating to the University of Northern Iowa job shadow or internship experience program for ______________ (insert month and year) through ______________ (insert month and year), including any property loss or damage, personal injury, and/or death resulting from any program activity. I understand and acknowledge that the program activities may include some risk or danger to the participant and/or the participant’s property, including but not limited to exposure to and/or interactions with chemicals, fumes, and other laboratory equipment and processes. I agree to release, indemnify, defend, hold harmless, discharge, and covenant not to sue the University of Northern Iowa, Board of Regents-State of Iowa, State of Iowa, their officers, employees, and agents, and all participants in the program (“the Releasees”) from and against all liability, loss, damage, or cost, including claims and suits at law or in equity, for injury, fatal or otherwise, and property loss or damage arising out of or related to my own or my child’s participation in the program and program activities, whether caused by the negligence of the Releasees or otherwise. I further agree that this Release shall be construed in accordance with the laws of the State of Iowa.

In the event of injury or illness, I give my consent for medical treatment and permission to program personnel to supervise or perform on-site first aid for minor injuries and to a licensed physician to hospitalize and secure proper treatment (including injections, anesthesia, surgery, or other reasonable and necessary procedures) for the participant. I agree to assume all costs related to any such treatment. I authorize my insurance company to pay benefits for the costs of such treatment. I also authorize the disclosure of medical information to my insurance company for the purpose of any claim. I also understand that I am responsible for any medical or other charges related to my own or my child’s participation in the program. 

I certify that the participant is physically capable of participating in the program activities. I have disclosed any physical limitations or medical problems that might limit the participant’s capability to perform program activities.

I HAVE CAREFULLY READ THIS ENTIRE RELEASE, WAIVER, AND MEDICAL AUTHORIZATION, FULLY UNDERSTAND IT, AND VOLUNTARILY AGREE TO BE LEGALLY BOUND BY IT.

PLEASE PRINT ALL INFORMATION EXCEPT SIGNATURES:

Minor's Name_______________________________    Minor's Signature_______________________________

Parent/Guardian Name___________________________________ Date_______________________________

Daytime Phone(_______)____________________    Evening Phone(_______)____________________

Parent/Guardian's Signature_______________________________ Date_______________________________

1. Complete and follow safety training specific to the hazards in a laboratory setting. 

2. Following the instructions of the sponsor or laboratory supervisor. 

3. Never participate on a scheduled assignment alone in any laboratory setting without direct adult supervision from the sponsor or someone designated by the sponsor. 

4. Follow general safety rules in laboratory settings, including but not limited to: 

• Wear closed-toe shoes while in any laboratory setting.
• Tie back long hair to keep it out of all hazards that may be found in laboratory settings.
• Never eat, drink, chew gum, apply lip balm, or touch contact lenses while in any laboratory setting.
• Wear clothing that reduces the amount of exposed skin. 

5. Wear personal protective equipment as directed and dispose of it appropriately. This personal protective equipment includes goggles, gloves, coats/gowns, and other face or body protection as dictated by the hazard with which you are working. Remove personal protective equipment when leaving the work area.

6. Immediately report any accident (regardless of severity) to the sponsor or laboratory supervisor. 

7. Keep your hands away from your face and wash them well with soap and water prior to leaving any laboratory setting and after removing gloves.

8. Ask questions if you do not understand the safety requirements.

BY MY SIGNATURE BELOW, I SIGNIFY THAT I HAVE READ THE RULES STATED ABOVE, UNDERSTAND THEM, AND AGREE TO FOLLOW THEM.

Minor's Name___________________________________________    

Minor's Signature_______________________________________ Date_______________________________

Parent/Guardian's Name__________________________________    

Parent/Guardian's Signature_______________________________ Date_______________________________

Lisa Frush
lisa.frush@uni.edu