Please read and sign below
By signing this application, I (or my parent or guardian on my behalf) hereby:
(A) acknowledge(s) and understand(s) that Harvard Medical School (HMS) Office for Diversity and Community Partnership and the Biomedical Science Careers Program, Inc. (BSCP) will retain the information in this application for its records , and that this information about the applicant, including identifying information, will be used to match students with advisors, track students through their academic and professional careers, and for future promotional and other communications, such as newsletters;
(B) consent(s) to photographic, audio, video, or electronic images of the applicant to be used by HMS and BSCP for exhibition, public display, publication, news media story, video, audio, or other electronic media, such as the Internet, television, CD-ROM, or DVD ;
(C) release(s) HMS and BSCP, including each of their directors, officers, employees and agents, waive(s)s all known and unknown claims against any of them, and agree(s) not to sue any of them on account of or in conjunction with any claims, causes of action, injuries, damage, cost of expenses arising out of the applicant's participation in the Symposium, whether or not caused by the acts, omissions or other fault of the parties being released; and
(D) acknowledge(s) and represent(s) that he or she has carefully reviewed this application, including the foregoing acknowledgement, consent, release, waiver and agreement not to sue and understand(s) what each of them mean, and that my/their signature below indicates that delivery of this application to HMS/BSCP is my/their free act and deed.
Name
Signature (your initials)
Date
MM/DD/YYYY
Please complete below if applicant is less than 18 years of age
Parent/Caregiver's Name
Parent/Caregiver's Signature (initials)
Date
MM/DD/YYYY |
