Diversity Hosting at Cornell University

Parent/Guardian Permission/Medical Authorization

and Rules Acknowledgement Form
April 2011

This authorization form must be returned to the Multicultural Recruitment Office at Cornell University to confirm
and reserve your space in the program and to finalize your travel arrangements.

Please Print Clearly

Student’s Name: ___________________________________________ Male _________Female ________

Address: ____________________________________ City: ____________ State: ______ Zip: ________
Home Phone: ( ) ___________________________ Date of Birth: __________________________
Cell Phone: ( ) __________________________ Requested Mode of Transportation: ___________
Student’s E-mail Address: _________________________________________________________________

Medical Insurance Information

Company: _____________________________________ Policy #: _______________________________

Home/Doctor’s Name:_________________________________________Phone: ________________________
Allergies (food and other): ____________________________________________________________________
Medications: ______________________________________________________________________________
Emergency Phone Number: _________________________________________________________________

Parent/Guardian Information

Parent/Guardian’s Name: ____________________________________________________________________

Parent’s Address: __________________________________________________________________________
Parent’s Work Phone: _____________________________ Parent’s Cell Phone: ________________________
Parent’s E-mail Address: _____________________________________________________________________

===============================================================================

I hereby give my child (name) _____________________________________________ permission to visit

Cornell University on ______________________. I understand that as a visitor to the university, my child will
be expected to exercise judgment as to participation in the many educational, recreational, and social activities
that are available and to assume full responsibility for his/her conduct during the visit.

Please check each box:

I understand that my child’s responsibilities are as follows:

Respect student host, his/her property, and time (especially sleep time).
Identify and discuss facilities & activities of interest with host.
Proper conduct and decisions regarding the visitation program and its activities, including refraining
from leaving the campus and riding in privately owned vehicles unauthorized by the university.
Awareness of and compliance with all program and university rules.

(OVER)
If your student is requesting air transportation please check these boxes:

I understand the following rules for FLIGHT visitation:

The university is only paying for the student’s travel expenses.

I am fully responsible for any fees associated with the cancellation of airline tickets – this includes sickness,
missed flights, and changes in my child’s availability.
I understand that I am responsible for making sure my child has a copy of the flight itinerary and that missing
any flight connections will result in my financial responsibility to get him/her on another flight to campus.
I have discussed the dates requested for travel with my child and have reviewed any prior commitments to
ensure a purchased ticket will not be canceled.
I understand that my child may have to take a red-eye flight in order to get to campus on the date requested.
I understand that I am responsible for making sure my child has proper identification and arrives at the local
airport in advance of his/her flight departure. I also understand that I am responsible for picking up my child
from the local airport on the day of the return flight.
Changes made to tickets must be approved by the Multicultural Recruitment Office. Payment for changes
must be made by me.
My child will check his/her email daily as flight arrangements are made daily by the travel agency. He/she
will call the university within 24 hours or as soon as possible to confirm the emailed itinerary. Changes to
flights will only be considered for emergency purposes.

If your student is requesting bus or car transportation please check these boxes:

I understand the following rules for CAR/BUS visitation:

My child is responsible for contacting the admissions office prior to a cancellation.

My child is responsible for requesting changes to a visitation request at least a week in advance.
I understand that my child’s registration fee will not be refunded in the event we cancel the day of the visit.
If driving my child to campus, I understand that I am responsible for arriving at the registration location
between the times requested by the university; I will contact the admissions office should any problems occur.

ALL PARTICIPANTS READ AND SIGN BELOW:

With full knowledge of the above and on behalf of myself, my child, my assigns, executors and heirs, I hereby release,
indemnify and hold harmless Cornell University (hereafter referred to as Cornell), its trustees, officers, agents and
employees from any and all liability, damage, claim of any nature whatsoever arising out of, or in any way related to my
child’s participation in this visit to Cornell, except those things due to the sole and active negligence of Cornell. In spite
of these facts, I have given my permission for my child to visit Cornell. If an accident occurs, I give my consent for
emergency treatment.

I have read and fully understand all provisions of this Permission/Release Form.

Parent/Guardian Signature: _________________________________________________ Date: ___________________

Guest/Child/Student Signature: _____________________________________________ Date: ___________________

Mail to: Undergraduate Admissions Office, Multicultural Recruitment, Cornell University

410 Thurston Ave, Ithaca, NY 14850

Or Fax: 607-255-0659, Attn: Multicultural Recruitment