Mini MASH faculty and staff aim to maintain a safe, positive, and educational environment for all participants. Certain behaviors can result in your immediate dismissal from the program and the notification of your parent/guardian. These behaviors include, but are not limited to:

I hereby grant permission for my son/daughter to apply to this program and for school officials to report my child's achievement and grades. I understand that if my son/daughter is accepted, we will be responsible for his/her daily transportation for the one-week program.

As the undersigned parent(s) or legal guardian(s) of a minor child, I (we) hereby consent to the participation of said child in a volunteer program and tour at Conway Regional Medical Center or other associated Hospital or Facility through the volunteer program. I (We) understand and agree that said child is to abide by all rules and requirements requested by Conway Regional and to conduct herself/himself in an appropriate manner.

I (We) understand that in the course of the child’s participation in this program and tour, he/she may have incidental exposure to confidential information. Confidential information includes all patient, employee, and student information and information of a proprietary, trade secret or otherwise confidential nature. I (We) agree that, during the child’s participation in the program and after the conclusion of the program, said child will not disclose the confidential information to anyone, including myself/ourselves, in any way or in any form without the specific written authorization of Conway Regional except as may be required by law.

I (We) hereby consent to and expressly authorize the release of said child’s name, hometown and the name of the school said child attends while child is participating in the program. I acknowledge that Conway Regional may release this information to stakeholders of the Programs, Arkansas Colleges and Universities, and others Conway Regional deems necessary to further the program. I acknowledge that this is a limited release of confidential student information under the Family Educational Rights and Privacy Release Act (“FERPA”).

I (We) understand that there are certain risks inherent to and associated with the activities of any facility in which patient care and research are conducted. I (We) agree on behalf of said child to the assumption of those risks and to not hold the University of Arkansas or its officers, board members, agents or employees responsible for any harm or injury from any cause, which may befall said minor child related to or arising out of the child’s participation in the program and/or tour of Conway Regional or associated facility or hospital and hereby release said entities and persons from any liability relating thereto. I (We) further agree to indemnify and hold said entities and persons harmless from the claims or causes of action asserted by any other person on behalf of said child, or in their own right, arising out of said participation. I (We) similarly agree to hold said entities and persons harmless from the claims of other persons arising out of any acts done by said child. I (We) understand and agree that this Agreement is not intended to include a release from harm caused by an individual’s criminal conduct or by the conduct of an individual constituting an intentional tort recognized under Arkansas law; and any such criminal conduct or intentional tort is against Conway Regional policy and therefore outside the scope of the person’s employment or relationship with Conway Regional  for which Conway Regional  is not vicariously liable. I (We) agree that these conditions and agreements are binding on all of my (our) heirs, executors, administrators, representatives, assignees and successors in action.

I (We) have read and understand the above and willingly agree to said terms and conditions. This authorization was signed voluntarily with the express understanding that this release will allow access by certain individuals to limited student information about said child that participates in this program.

I am aware that regular attendance at the Program and adherence to both Conway Regional Health System and UAMS policies and procedures will be required of my child.

I, the undersigned, hereby give Conway Regional Health System, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by Conway Regional Health System or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the website or social media sites(e.g., Facebook, YouTube).

I hereby release, discharge, and agree to save harmless Conway Regional Health System, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same.

I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.

I hereby warrant that I have read this agreement in its entirety before affixing my signature thereto, and I fully understand the contents therein. I further warrant that I am of legal age and competent to contract my own name as far as the above is concerned.