PERMISSION/WAIVER OF LIABILITY/MEDICAL RELEASE FORM
This form is required for any visiting student staying overnight on campus and must be completed in its entirety. Once this form is completed, please email to discovergcu@gcu.edu. Forms must be received at least three days prior to your visit. Students will NOT be allowed to stay overnight without having completed this form.
DATE OF DISCOVER GCU EVENT: October 9th, 2015
VISIT ARRANGED BY (please select one):
Admissions Representative

Representative’s Name

Online Registration
Athletic Department

Coach’s Name:

STUDENT INFORMATION:
Name of Student: Olivia Rivera
Cell Phone: 6029040593
Student Address: 6315 W. Golden Lane
Gender: Female

Date of Birth: July 7th, 1998

High School or Recent College: Centennial High School Degree Program of Interest: Nursing

HS Graduation Year: 2016

METHOD OF TRANSPORTATION TO CAMPUS:
Individual Flight (Grand Canyon University provides a shuttle service to and from the airport at specific times)
Group Fly-In

OR

Group Bus (Transportation provided by Grand Canyon University Admissions)

 Parent Drop-Off (Parent must accompany student to and from campus if the student is under 18 years old)
Self-Driver (Must be 18 years or older and pick up a parking pass from security kiosk)

ALLERGIES/MEDICATIONS:
Medical Insurance Name and Policy #: United Health Care & 911-87726-04
Student’s Allergies: N/a
Student’s Current Medications: N/a
(Include Special Instructions: EpiPen, dosage, diabetic procedures, etc) N/a

3300 West Camelback Road, Phoenix, AZ 85017 | gcu.edu

PERMISSION/WAIVER OF LIABILITY/MEDICAL RELEASE FORM
EMERGENCY CONTACT:
Name: Margarita Rivera

Relationship: Mother

Phone: 6029040582
Parent Pit Stop:

Yes

No

If yes how many guests attending:

PARENT/GUARDIAN INFORMATION (if minor student):
Name of Parent or Guardian: Margarita Rivera
Email: lamontandmargarita@yahoo.com
Attending Parent Pit Stop:

Yes

No

Cell Phone: 6029040582

If yes, number of guests attending:

PERMISSION/WAIVER OF LIABILITY/MEDICAL RELEASE/PHOTO RELEASE:
I hereby release, indemnify and hold harmless Grand Canyon University, its trustees, officers, agents and employees from any and all liability, damage, or claim arising out of or in any way related to my participation (and/or my child’s participation if a minor) in this visit to Grand Canyon University, except where such claims are due to the sole gross negligence of the college, its agents, or employees.
I grant Grand Canyon University permission to use my photographs (and/or those of my child if a minor) in print, web, electronic, and video formats or in other official Grand Canyon University print publications. If signing on behalf of a minor child, and I cannot be reached in case of emergency, I the undersigned parent or guardian of the above-named child, do hereby authorize a representative of
Grand Canyon University to consent to any medical treatment or care deemed advisable.
I have read and fully understand all the provisions of the Permission/Release form. I have also read and agree to comply with the
Visitation Policy and the guidelines outlined in the Grand Canyon University Student Code of Conduct.

Signature of Student: Olivia Rivera

Date: 09/17/15

Signature of Parent/Guardian (if minor student): Margarita Rivera

Date: 09/17/15

RETURN FORM 3 DAYS PRIOR TO VISIT: scan and email to DiscoverGCU@gcu.edu or fax to 602-761-3328. If issues arise, please contact the Discover Event Coordinator, Tara Scibona, at 602-639-7158 or tara.scibona@gcu.edu

3300 West Camelback Road, Phoenix, AZ 85017 | gcu.edu
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