Exclusion Of Liability And Indemnity Form For Access To Facility
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1THIS MUST BE COMPLETED AND RETURNED TOGETHER WITH YOUR ACCEPTANCE FORM
TO THE RELEVANT DEPARTMENT/FACULTY/SCHOOL/OFFICE IN WHICH THE FACILITY RESIDES.
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VISITORS BELOW 18 YEARS OF AGE ARE REQUIRED TO HAVE THEIR PARENT COMPLETE THIS FORM
.
EXCLUSION OF LIABILITY AND INDEMNITY FORM FOR ACCESS TO FACILITY
I,
_____________________________________________
(Name
of
*visitor/parent/guardian)
__________________________________________ (Passport/Identity Card No.), *parent/guardian of
__________________________________________ (Name of visitor) _____________________
(Passport/Identity Card No.), hereby request that *I/my child/my ward be granted access to
________________________________________________________________ (Name of laboratory,
workshop or animal facility) (“Facility”). In consideration of *I/my child/my ward being granted access
to the Facility by ___________________________________________________________________
(Department/Faculty/School/Office), National University of Singapore, I, for myself, *and my child/my
ward, my successors, personal representatives and assigns, hereby agree as follows:
(a) I acknowledge that access to the Facility involves an inherent risk, including risk of personal
injury, ill-health and/or exposure to disease or infection, and that *I/my child/my ward will have
access to hazardous facilities, equipment, and materials.
I further acknowledge that *I/my
child/my ward make(s) use of such access, facilities, equipment and materials of *my/his/her own
free will and volition and *am/is aware of and accept(s) the risks involved.
(b) I/my child/my ward* will abide by the applicable written and verbal rules (including safety rules),
regulations, policies, procedures, guidelines, protocols and instructions established or prescribed
from time to time by the University or its departments, faculties, schools, offices or relevant units
regarding the use of the Facility and the facilities, equipment and materials therein, failing which,
the University shall be entitled to immediately withdraw access to the Facility and any and all
privileges arising therefrom.
(c) I will not hold the University, its officers, any of its full-time or part-time staff (including student
assistants), agents or volunteers responsible or liable in any way for, and no action shall arise
from, any loss or damage (including, without limitation and to the extent permissible by law,
personal injury, loss of life or property damage) caused by or sustained as a result of *my/my
child’s/my ward’s access to the Facility or use of the facilities, equipment and/or materials therein.
(d) I will indemnify and indemnified, save and hold harmless the University its officers, any of its full-
time or part-time staff (including student assistants), agents or volunteers against all losses,
claims, demands, actions, proceedings, damages, costs or expenses, including legal fees, and
any other liability arising in any way from *my/my child’s/my ward’s access to the Facility or use of
the facilities, equipment or materials therein, or resulting from any breach of the undertakings
herein.
Signature of *visitor/parent/guardian:
Name (please print):
Passport/Identity Card No.:
Relationship to visitor, if applicable:
Telephone (Residence):
(Office):
Mobile Telephone:
Fax:
Email Address:
Postal Address:
Date:
* Delete as applicable.
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Where parents are deceased, a visitor below 18 years of age should provide the name of a legal guardian or any other person
who has legal authority over, and responsibility for, the visitor.
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