Vanderbilt University Protection of Minors Release, Authorization and Permission for Self-Check-Out

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Vanderbilt University Protection of Minors Release, Authorization and Permission for Self-Check-Out

For the safety of your child, we must have on file, a written waiver/authorization/permission form (hereinafter “permission
form”) from the parent/legal guardian, permitting your child to depart the program without parental check out. Protection
of Minors Policy Guidelines do not permit participants under 14 years of age to self-check-out. Programs may have program
policies above the guidelines in which the age permitted is higher. Programs are fully supported by the University in the
decision to increase this permitted age.

PROGRAM NAME: __________________________________________________Date(s) of Applicability: ________________

NAME OF MINOR: AGE _______ DATE OF BIRTH: ______________


Please note that this permission form grants permission for the minor to leave the above program or camp at the scheduled
end time without adult supervision. Participants will only be released at the scheduled program ending time, or at another
time designated to the program in writing or in person by the parent/legal guardian. If the Program identified above does
not have a fully executed permission form on file, your child will not be released without authorized adult supervision. You
will be called to pick him/her up at the end of the program.
Minors are not permitted to be unsupervised on Vanderbilt campus property. If this permission is granted the minor is
expected to depart the campus at the close of the day’s activities, unless the minor is joining a parent at a location on
By signing this permission form, I authorize my child listed above to be dismissed at the scheduled end time of the Program
identified above. This includes permission to drive (if personal vehicles are permitted in the program), walk, use of public
transportation, walk home from the participant’s regularly scheduled bus stop and includes waiting at the bus stop
unsupervised, and use of shuttle service as arranged through the program. I understand and agree that Vanderbilt
University (hereinafter “Vanderbilt”) accepts no responsibility for my child’s acts or the acts of others that are in anyway
associated with my child being allowed to self-check-out. I hereby release and hold Vanderbilt harmless from any and all
liability or claim of liability for bodily injury or property damage arising out of or in connection with participation in the
Program, including but not limited to my child’s self-check-out from the Program, except such liability or claim of liability as
may result from gross negligence on the part of Vanderbilt.
This form is not to be used to designate carpools for adult pick up of participating minors.

Parent/ Legal Guardian Signature:

Special Instructions:
or cancel