University of Southern Mississippi
Boat Operations
This form must be signed and on file with the Vessel Operations Manager before a minor person will be allowed to board any vessel belonging to, or chartered by, The University of Southern Mississippi.
Please complete this form and return to:
Tiffany McNeese, Vessel Operations Manager Gulf Coast Research Lab (228) 872-4277
703 E Beach Dr. Ocean Springs, MS 39564
Student’s Name ______Date of Birth ______
Address ______
Mother/Guardian’s Name ______Cell/Work Phone ______
Address ______Home Phone ______
Father/Guardian’s Name ______Cell/Work Phone ______
Address ______Home Phone ______
Emergency Contacts
Names of two (2) contact persons in case parent or guardian cannot be reached:
1. Name ______Relationship ______
Home/Cell Phone ______Work Phone ______
2. Name ______Relationship ______
Home/Cell Phone ______Work Phone ______
Medical Release
FOR AND IN CONSIDERATION of allowing ______
Print Participant’s Name
to board any vessel owned or chartered by the University of Southern Mississippi and used for instructional or research purposes and in allowing same to participate in activities conducted on said vessel, I, the undersigned, hereby and herewith voluntarily consent to and waive the responsibility of University of Southern Mississippi, its officials, or agents, for any mishap or injury to said person or property of said person while embarking, while on board, or while disembarking from said vessel. I the undersigned, further hereby indemnify The University of Southern Mississippi, its officials or agents, from any injury or damage to the person or property of said person that may arise out of allowing said person to participate in any of the aforementioned activities.
This is to certify that ______is free from sickness or disabilities
Print Participant’s Name
which would make participation in any form of activities aboard ship dangerous or inadvisable. This health statement is correct as far as I know, and the person herein named has permission to engage in all prescribed vessel activities, except as noted by me (parent/guardian of minor) or a physician. In case of emergency, I understand every effort will be made to contact parents/guardians of the participant. In the event they cannot be reached, I hereby give permission to the physician selected by The University of Southern Mississippi Staff to secure proper emergency treatment for and to hospitalize, order injection, anesthesia, or surgery for person herein described.
Date of participant’s last tetanus shot? ______
Participant is covered under the following medical insurance policy(ies):
Insured’s (Parent/Guardian) name ______
Insurance company ______Policy number ______
Additional policy name and number ______
Insured’s Soc. Sec. Number ______Insured’s date of birth ______
Name of Physician ______
Physician’s Address ______
Office Phone ______Emergency Phone ______
Medical Needs
List of Allergies (to drugs, insect bites, foods, etc.)
______
______
______
Other Known Medical Conditions
______
List of medications participant is taking or may need to take. Please include reason for taking the medication.
______
Dietary Needs/Restrictions
______
The University of Southern Mississippi, while exercising every precaution, will not be responsible for the personal injury, medical bills obtained from personal injury/sickness or loss of property, however occasioned. The execution hereof by the participant (parent/guardian of minor under age 21) constitutes an agreement to hold The University of Southern Mississippi harmless for such injury or loss.
Parent/guardian’s signature______
Parent/guardian’s printed name ______
Date ______