Campus Safety

* Required

Guests

Elizabethtown College Overnight Visit Release

The information collected on this form is confidential and will only be shared in an emergency.

Guest Information

Guest Name:

Date of Visit

Number of nights on campus

Guest Address:

City:

State:

Zip:

Guest Cell:

Guest Date of Birth:

PARENT INFORMATION

Parent/Guardian Name:

Phone Number:

EMERGENCY CONTACT INFORMATION

1st Emergency Contact Name:

Relation To Guest:

Phone Number:

2nd Emergency Contact Name:

Relation To Guest:

Phone Number:

INSURANCE INFORMATION

Insurance Company Name:

Policy/ID Number:

Group Number:

(EMS will be contacted and parents/guardians will be notified in the event of a medical emergency.)

WAIVER/RELEASE INFORMATION
In consideration for the permission granted by Elizabethtown College for this guest to participate in this Overnight Visit, on my behalf and on behalf of the guest and each of my and the guest's heirs, executors, and administrators, I hereby waive and release any and all causes of action, claims, suits, damages and judgments, in any form whatsoever, arising from or by reason of any and all known or unknown, foreseen and unforeseen bodily or personal injuries (including death) or property damage, resulting from the guest's participation in the Overnight Visit and related activities, against Elizabethtown College, and their employees, administrators ,trustee, volunteers, and agents.

In witness whereof, and intending to be legally bound, I have executed this document below.

Parent/Guardian Signature:

Date:

VEHICLE INFORMATION
If you will have a car on campus overnight, please provide the following information:

Vehicle Make and Model:

Vehicle Color:

State

Plate Number:

PERSONS WITH DISABILITIES
Elizabethtown College is committed to providing full access to all courses, programs, services and activities. For questions concerning disability related accommodations for the overnight visit program, please contact Paula Orenstein, Senior Associate Director of Admissions at (717) 361-1400.