Parental Permissions

Programs must ensure that every minor’s parents have signed the Parental Permission Agreement. The Minor Program Administrator may audit Programs to ensure compliance.   Please contact the Minor Program Administrator for the proper Parental Permission Agreement.  A sample may be viewed below:


Cornell University
<Insert department and program name>
<Insert program dates>


Child’s name (Print): ________________________________________

I, the undersigned, hereby expressly and affirmatively state that I wish to allow my child to participate in the <Insert name of program> (“program”). I realize, and accept, that participation involves risks of injury and illness that may arise due to my child’s participation in this program and that it is not possible to specifically list every individual risk of injury and illness. However, knowing the material risks and reasonably anticipating, appreciating, and knowing that other injuries and illnesses are a possibility, I hereby expressly assume all of the delineated risks in the program.

In consideration of the opportunity for my child to participate in this program, I hereby for myself and on behalf of my heirs, family members, executors, administrators, assigns, personal representatives and next of kin, agree to HOLD, Cornell University, their respective trustees, officers, agents, volunteers, and employees (collectively, “Released Parties”) HARMLESS from any liabilities, damages, expenses, causes of action, claims, or demands of any nature whatsoever, including any claims of negligence, on account of personal injury, property damage and death, related to this program.

I understand that Cornell University does not provide any Accident or Medical Insurance for this program and that I am required to provide this for my child. I agree that I am financially responsible for all such expenses whatsoever and wherever incurred.

This Parental Permission and Hold Harmless Agreement shall be governed by the laws of the State of New York, without regard to conflicts of laws principles. I agree that any dispute about the terms of this Agreement shall be presented to a court of competent jurisdiction in the State of New York with venue in Tompkins County.

I further certify that I have read this entire Agreement, and understand the dangers involved in participating in this event. I am fully aware of the legal consequences of this Agreement and I agree to its terms. I represent and warrant that I am eighteen (18) years of age or older and have legal authority to execute this Parental Permission and Hold Harmless Agreement.

Parent/Guardian Name

Parent/Guardian Signature