Trip Application-Liability Release Form printable pdf download

UVM Outing Club

Trip Application & Liability Release Form

Name:________________________________ Major: _____________Class: _________

Local Address:_____________________________________Phone:_________________

Permanent Address:_______________________________________________________

street town state/zip

E-Mail: ______________________________ Date of Birth: ______________________

Permanent Phone: ( )_________________ Emergency Contact: _________________

Parents or Guardian: ____________________ Phone Number ( )_________________

I currently carry Medical Insurance? Yes_____ No_____ Group #___________________

Name of Insurance Provider: ________________________________________________

Type of Trip:___________________________ Location:__________________________

THIS IS A WAIVER AND RELEASE OF LIABILITY. PLEASE READ CAREFULLY.

As a participant on a UVM Outing Club Trip, I realize that inherent dangers exist. While in good health and able to

fully participate in such activities, I realize my participation may result in illness or injury due to accidents, the

forces of nature or other causes unforeseen. Such illness or injury may include disease, strains, sprains, fractures,

dislocations, paralysis and/or death. By participating, I hereby and knowingly assume all risk resulting from these

activities.

On behalf of myself, my family or other personal representatives I hereby agree to release, hold harmless and

indemnify the UVM Outing Club, its agents, officers and wilderness leaders from any and all claims and law suits

for bodily injury, property damage, wrongful death, loss of services etc. which may result from my participation in

the above mentioned activities, regardless of whether or not these claims or suits arise from negligent acts,

omissions by the UVM Outing Club organizers, leaders or facilitators of the activity, employees or volunteers,

another participant, any other person involved or from any other cause.

I HAVE READ THE ABOVE WAIVER AND RELEASE. I UNDERSTAND THAT I HAVE

RELINQUISHED SUBSTANTIAL RIGHTS BY SIGNING IT AND DO SO VOLUNTARILY.

Printed Name: _______________________ Signature:___________________________

Signature of Parent or Guardian

(If participant is less than 18 Years of Age): ____________________________________

Date: ______________________________

Trip Application-Liability Release Form