Youth Protection Forms

If you prefer to complete this document by physical copy, you can download the pdf version and return it to WashU Admissions at admissions@wustl.edu.

LIABILITY WAIVER AND RELEASE

Contact Information

Student's Full Name

Birthdate

Country

Street

City

Region

Postal Code

Parent/Legal Guardian Full Name

Phone Number

Parent/Legal Guardian Email Address

In consideration for, and as a condition of, my child’s participation in the educational experience provided by Washington University in St. Louis (“WashU”) described below, I, the undersigned, on behalf of my child and myself, agree as follows:

Permission: I grant permission for my child

to participate in the WashU Campus Visit Program (“Program”) including travel, field trips, and stay in on-campus accommodations offered by WashU during 2025-2026 academic year. I understand and agree that my child’s participation in the Program is voluntary. I understand that some of these activities may include bus, light rail, or automobile transportation and give permission for my child to be transported as necessary.

Rules & Policies: My child and I agree to obey all Program rules and policies, any policies of WashU applicable to the Program.

Media Release: I, the undersigned, hereby irrevocably grant permission to WashU to photograph, film, reproduce, transcribe, or otherwise record and use (including release, publish, quote, or broadcast) my child’s image and/or voice in connection with the Program. Additionally, I hereby authorize WashU, to release, publish, broadcast, or quote such material, including my child’s first name, and any program-related material my child may create (including photographs and writings). With respect to this material, I understand that content may be included in future speeches, on the Internet, and through multiple broadcast channels and print media, but that such content will not be used for commercial purposes. I understand that neither I nor my child will receive monetary compensation in exchange for use of products that include such material.

Liability Release and Indemnity: I understand and appreciate the dangers, hazards and risks inherent to the Program, including but not limited to transportation to, from, and around the Program locations, natural disasters, inclement weather, exposure to rain, cold or excessive heat, dehydration, accidents, falls, lacerations, burns, broken bones, insect or other animal bites, and other, illnesses, diseases, crimes, riots, terrorist activities or attacks, and any risks associated with independent activities my child undertakes as an adjunct to the Program, all of which could include serious or even fatal injuries or property damage or loss. Such damage, injuries and/or death may result not only from my child’s own action, inaction or negligence but also the action, inaction, or negligence of others. I further understand that WashU, including the individuals acting on its behalf, cannot and does not assume responsibility for such events or personal injuries or property damage arising therefrom even if such injury or damage is a result of the negligence of WashU or other parties released. I also accept that it is my child’s sole responsibility to participate only in those activities for which my child has the prerequisite skills, qualifications, preparation, and training, and that I have read and understand the conditions applicable to the Program. I further accept and agree that my child will follow all instructions pertaining to the Program, particularly those regarding safety and security practices.

With full knowledge of the dangers, hazards and risks of the Program, and in consideration of my child being permitted to participate in them, on behalf of myself, my child, my family, heirs, and personal representative(s), I agree to assume all the risks and responsibilities surrounding my child’s participation in the Program and, in advance, release, waive, forever discharge, and covenant not to sue WashU, its governing board, officers, agents, employees, students, and volunteers (collectively, the “Releasees”) from and against any and all liability for any harm, damage, claim, demand, action, cause of action, cost or expense of any nature that I or my child may have or that may hereafter accrue to me or my child, arising out of or related to any loss, damage or injury, including but not limited to physical injury, suffering or death, that may be sustained by my child or by any property belonging to my child, whether caused by the negligence or carelessness of the Releasees with regard to the Program. This waiver does not pertain to incidents involving gross negligence or willful misconduct by WashU and/or its agents. It is my express intent that this Release shall be deemed a release, waiver, discharge and covenant not to sue the Releasees. I further agree to save and hold harmless, indemnify, and defend Releasees from any claim by me, my child or my family arising out of my child’s participation in the Program.

Health and Safety Policy Guidelines: All members of our community – students, faculty, staff, and visitors - are expected to adhere WashU public health policies and guidelines, in addition to other public health orders, regulations and laws. These policies and guidelines are in place to help mitigate the spread of infectious diseases on campus and in the surrounding community. Public health concerns may result in a disruption, alteration, or other modification to the Program, including but not limited to a shortened term, transition from in-person program delivery to remote learning, or reduction or elimination of breaks. The Program is subject to change as deemed necessary by the University to address public health concerns.

Medical Conditions, Disabilities and Accommodations: My child has the following medical condition(s) or disabilities of which University should be aware while my child is participating in the Program. I understand that if any condition constitutes a disability that would make it difficult for my child to participate in the Program, I am to contact the program director.

Medical Condition(s) or Disabilities:

I am aware of my child’s personal medical needs and state that there are no health-related reasons or problems that preclude or restrict my child’s ability to participate safely in the Program. I assume all risk and responsibility for my child’s medical needs and understand and agree that if my child must be hospitalized or otherwise receive medical care, WashU cannot and does not assume legal responsibility for payment of such costs. I hereby warrant that my child has adequate health insurance coverage to meet any and all needs for payment of medical costs while undertaking the Program. I hereby grant permission to the Releasees to authorize emergency medical treatment for my child and understand and agree that neither WashU nor any of the other Releasees assume any responsibility for any injury or damage that may arise out of or in connection with such authorization.

I understand that the use or possession of alcohol or any illegal drugs, including marijuana, by my child is strictly prohibited. I know that my child is subject to local law and that my child agrees to obey all laws and ordinances of jurisdictions where my child may be during their participation in the Program. I understand that if my child does not behave in accordance with policy and law, they may be asked to leave the Program and will be responsible for all personal expense thereafter, including return transportation, and may be prohibited from attending future WashU events.

No Photography, Videotape or Audiotape: My child and I will not photograph, videotape, audiotape or otherwise record ourselves or other participants in the Program or the course content during the Program (except as allowed as an accommodation for a disability).

Acknowledgement: I certify that I am the parent or legal guardian of the above-named child, that I have read this document, and that I am relying wholly upon my own judgment about the risk of injury to my child by my child’s participation in the Program. I am over the age of 18 and am voluntarily signing this agreement as my own free act fully intending to be legally bound by it.

I agree that this Waiver and Release shall be construed in accordance with the laws of the State of Missouri. If any term or provision of this Release shall be held unenforceable, illegal, or in conflict with any governing law, the validity of the remaining portions shall not otherwise be affected.

THIS DOCUMENT CONTAINS A RELEASE OF LEGAL RIGHTS. READ IT AND BE CERTAIN YOU UNDERSTAND IT BEFORE SIGNING

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Version

MEDICAL HISTORY AND TREATMENT AND AUTHORIZATION

Student Name

Preferred First Name

Sex

Please list and/or describe any current medical conditions

List all medications (prescription or over-the-counter), vitamins, or supplements and include the reason for medication and dosage.

List any medications you are allergic to and describe the reaction.

Do you have any allergies (foods, bees, or other stinging insects)?

Please describe including if reaction may result in anaphylaxis and list of emergency medications.

Do you have any special housing, dietary, or other needs?

Please describe

Medical Insurance

Name of Insurance Company

Policy Number

Group Number

Additional Information

Authorization for Medical Care

To the best of my knowledge, my child/participant is capable of participating safely in the Program and that any activity restrictions, allergies, and medications are listed on this form. As a participant, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in harm to participant and/or others during this Program. By signing my name I represent and warrant that I have provided all materials and important information to the Program pertaining to Participant’s medical, mental and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in my child’s mental, physical or medical condition prior the scheduled Program.

Missouri law provides, as a general rule, that medical, surgical, and mental health care may not be provided to a minor (a person under 18) without consent. In order to facilitate the prompt provision by the Student Health and Counseling Services of both
routine and emergency care, a student’s parent/legal guardian must sign the following statement:

I consent and give my permission for my child/ward to receive medical, surgical, and mental health care deemed advisable and appropriate by the Student Health Center or by a physician, health care worker or hospital selected by the Student Health Center. I understand that, except in an emergency, no surgical operation (other than a minor office procedure) will be performed on my minor child/ward without my being contacted and fully informed. I hold harmless and agree to indemnify the Program and Washington University in St. Louis from any claims, causes of action, damages and/or liabilities arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my child that may occur during his/her participation in this Program.

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PICK UP AUTHORIZATION

My student will be traveling to campus by:

This form is only required if your student is traveling by car. Please continue to the next form.

Which FLI-in Theme is your student attending?

Pick-up Date: Friday, June 26, 2026
Time: 12:30 - 2:00pm

Pick-up Date: Friday, July 10, 2026
Time: 12:30 - 2:00pm

Pick-up Date: Friday, July 17, 2026
Time: 12:30 - 2:00pm

Pick-up Date: Friday, July 24, 2026
Time: 12:30 - 2:00pm

Pick-up Date: Friday, July 31, 2026
Time: 12:30 - 2:00pm

Participant's Name

Parent/Legal Guardian Full Name

Please list any individual who is authorized to pick up the Participant, including yourself. Each authorized person must be at least 18 years of age. The above-named Participant will not be permitted to leave the Program with anyone who is not listed below. Authorized individuals must pick up Participant in person and may be requested to show identification to Program staff when picking up a Participant. Participants will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible person to pick up my child from the aforementioned Program activities:

Authorized Person's Full Name

Phone Number

Relationship to Participant

The following individuals are not permitted to pick up my child:

Unauthorized Person's Full Name

Brief Physical Description

Relationship to Participant

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CODE OF CONDUCT

By deciding to attend the Program at Washington University in St. Louis (WashU), students commit themselves to maintaining the highest academic and social standards. As a member of the Program community, students are expected to make a positive contribution by acting responsibly and by respecting the rights of other students, faculty, and staff. Please read the following expectations carefully.

Violations of any of the following may result in disciplinary actions including limitation of activities or expulsion from the program:

WashU encourages and gives full consideration to all applicants for admission, financial aid, and employment. The university does not discriminate in access to, or treatment or employment in, its programs and activities on the basis of race, color, age, religion, sex, sexual orientation, gender identity or expression, national origin, veteran status, disability or genetic information. It is our expectation that our students do not discriminate or harass others on such basis as well.
Students are expected to conduct themselves in a responsible manner, with respect for the rights and property of others, and are expected to abide by all applicable federal, state, and city laws.
WashU prohibits smoking or the use of any tobacco products anywhere on campus. Students are not permitted to have tobacco products, electronic cigarette or other vaping devices, or tobacco paraphernalia of any kind including rolling papers, matches, or lighters.
Students are not permitted to possess or have unsupervised use of knives of any kind including pocket knives, x-acto knives, or kitchen knives.
Students are expected to attend all scheduled program activities unless otherwise excused by staff or instructors. Over 3 unexcused absences from program activities is grounds for dismissal.
Students are expected to be engaged, professional participants and complete all program responsibilities.
Any damage to WashU property or the private property of other students will be repaired at the expense of the student(s) responsible for that damage.

The following are strictly prohibited and violations will result in immediate dismissal from the program:

Consumption, use, or possession of alcohol or unlawful drugs; abuse or distribution of prescription drugs; possession of paraphernalia that can be used for illegal drug use; possession or use of weapons, explosives, or fireworks; sexual misconduct or harassment; physical altercations or bullying of any kind. Such conduct may also expose students to criminal prosecution by state or federal authorities.
- This policy also extends to objects or means employed to induce results or effects similar to intoxication or impairment but which are not necessarily illegal, e.g., “whip-its,” “bath salts,” use of over-the-counter medicines for such purposes, asphyxiation and so on. In such cases where means are not illegal to have in possession, intent to use for purposes of intoxication or impairment will be the determining factor in dismissal.
- If there is suspicion of consumption, use, procurement, or possession of alcohol, unlawful drugs, weapons, explosives, fireworks, paraphernalia, or items with intent to impair a room check will occur in the presence of WashU police, Residential Life and Program personnel. Posts or photographs on social media as well as statements made by students or staff are considered grounds for suspicion.

Residential students must abide by the following additional guidelines. Violations of any of the following may result in disciplinary actions including limitation of activities or expulsion from the program:

A curfew for all Program students is strictly enforced. Students must be in rooms by 11:00pm every evening. Quiet hours are also strictly enforced beginning at 11:00pm until 7:00am.
Students are not permitted to move from assigned rooms unless authorized by the program director. Students are not permitted to have any overnight guests, including other residents, in their rooms or suites.
Student housing is organized based on age and year in school. Students are not permitted at any time in residential suites that are assigned to students of different gender identities than their own.
During program dates students are not allowed to leave campus unless part of a scheduled program activity under supervision of program personnel.
- Students are not permitted to leave campus in a vehicle operated by someone other than their parent/legal guardian unless prior authorization from their parent/legal guardian is received.
Students are not permitted to bring or have access to motor vehicles while residing on campus.
Students are expected to respect residential/overnight facilities and to keep them clean. This includes common areas, suites, restrooms, and individual rooms.
Students are not permitted to host parties or get-togethers at their home or other off-campus locations.

We have read and understand the above Code of Conduct for all Program students. We further understand that failure by the student to abide by these regulations and guidelines or to respect the authority of program staff in their enforcement may result in sanctions including, but not limited to: limitations on activities, restitution for property damage, or expulsion from the program. Furthermore, if expulsion of the student is necessary, we understand that we will be responsible for travel expenses for the student to return home within 24 hours of notification of expulsion.

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