I/We understand that CUA does not provide health insurance for the individuals participating in the
activities made available or sponsored by the University and I/We will be responsible for payment of
medical services and care for any injuries sustained during the designed activity. I/We authorize
the University/program at its discretion and my own expense to obtain medical service, surgical
care or treatment for Participant in the event of an emergency. This authorization is given with the
understanding that the University will attempt to notify the Participant’s Parent/Guardian in
emergency contact in the event of the emergency. I/We confirm that it is my/our desire that
Participant be furnished with such medical care, surgical care or treatment services as soon as
reasonably possible after the need arises. I/We hereby release and hold CUA harmless from any
liability which might arise from the giving of such consent. I/We agree to reimburse the University
for any medical expenditure made on the Participant’s behalf.

I am at least 18 years old, and I enter this agreement voluntarily.