Grandparents' University Medical Release And Assumption Of Risk printable pdf download

Grandparents’ University

Medical Release and Assumption of Risk

Participating Grandparent Name:_________________________________________________

I am aware that the Grandparents’ University program includes physical activities in which I am

expected to participate. These activities involve a potential risk of fatality, bodily injury, and

property damage. I have provided University Student Housing with all medical information that

should be considered if I am not able to participate in parts of the program. I hereby release

University Student Housing and its staff, West Chester University, its faculty and staff from any

and all liability for any accident or injury that may occur during this program, whether caused

by negligence or otherwise. Listed below is the name of my medical insurance carrier and my

policy number and emergency contact.

Insurance Information:

Name of Health Insurance Provider____________________________ Policy Number_______________

Primary Physician______________________________________________________________________

Address_______________________________________

Phone Number_______________________

Emergency Contact Information:

Contact Name: __________________________________ Cell Phone: _________________

Email Address: ___________________________________ Home Phone: _______________

Relation to Participant: ___________________

Assumption of Risk:

I understand that the Grandparents’ University program involves a potential risk of fatality,

bodily injury, emotional distress, and property damage. I agree that I am solely responsible for

my own physical and emotional well-being. I further affirm that my health is good. I willingly

and knowingly assume for myself, my heirs, executors, administrators and assigns all risk of

fatality, physical injury, property damage, and/or emotional distress which may occur during or

after participating in any aspect of the program and hereby agree to hold West Chester

University, University Student Housing, its employees, staff, instructors, facilitators and agents

harmless for any liability arising out of my participation if the program , whether caused by

negligence or otherwise.

______________________________________________________________ Date_______________

(Signature of Participating Grandparent)

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Grandparents' University Medical Release And Assumption Of Risk