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Risk Assessment And Release Form

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Risk Assessment and Release Form

I, ______________________, fully recognize that there are certain risks

and responsibilities to which I may be exposed by participating in the

following activity ________________ during ______________________.

Although

designed to enhance my general education, participation in this trip and

program is entirely voluntary and is not required as part of any academic

program or course.

The following is a description and list of examples of

specific, significant, non-obvious dangers and risks associated with this

activity.

The dangers and risks listed are not exclusive and I realize that

other significant risks and dangers may be present in the activity:

_____________________________________________________________________________

HEALTH INSURANCE, EMERGENCY INFORMATION, AND AUTHORIZATION

•

I understand that I am responsible for providing my own health

insurance.

•

The following person should be contacted in case of emergency:

Name: _____________________________________________

Relationship: _____________________________________

Address: __________________________________________

Telephone: ________________________________________

•

If I become injured or ill while participating in the program, I hereby

authorize ______________________ to act on your behalf in obtaining

medical treatment.

I understand and agree that I am fully responsible

for all expenses incurred for any medical care I receive during the

program.

By signing this form, I acknowledge that I have been informed about certain

risks and responsibilities involved in this program and that I am knowingly

and voluntarily assuming them.

By signing this form I also agree, for

myself, my heirs and assigns, to release and hold harmless George Mason

University, its employees and agents, from any legal claim or liability for

any bodily injury and personal property damage that is caused to me by the

negligent act or omission of third parties, arising from my activities under

this agreement.

Signed: ____________________________

Date: ____________

If the participant is under 18 years of age, a parent or legal guardian must

also sign:

Signed: _____________________________

Date: ____________

RMO Form 02A

Rev Apr 2007

Risk Assessment And Release Form

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