Waiver Sheet - University Of Alberta printable pdf download

PARTICIPANTS SIGN-UP SHEET, RELEASE OF LIABILITY, ASSUMPTION

OF RISK AND INDEMNITY AGREEMENT

Indian Student Association

Annual Summer Trip, Jasper AB (July 2

, 2016)

WARNING!

BY SIGNING THIS FORM YOU GIVE UP IMPORTANT LEGAL RIGHTS

INCLUDING THE RIGHT TO SUE

PLEASE READ CAREFULLY! PARTICIPANTS MUST BE 18 OR OLDER

Name of Participant

Last Name:

First Name:

Street Address:

City:

Province:

Country:

Postal Code:

Phone Number:

(

)

Email Address:

Identification number:

Birth Date:

mm/dd/year:

(Student or Employee ID)

Emergency Contact:

Last Name:

First Name:

Relationship:

Phone Number:

(

)

EXT:

DISCLAIMER CLAUSE

Indian Student Association; the Students' Union, University of Alberta, and the Governors of the University of Alberta, their executive, officers, directors,

employees, volunteers, members and representatives (hereafter referred to as "the Club") are not responsible for any injury, loss or damage of any kind

sustained by any person while participating in the Annual Summer Trip, Jasper AB and all related activities (hereinafter referred to as “club activity”),

including injury, loss or damage which might be caused by the negligence of the Club.

ASSUMPTION OF RISKS

“club activity”

In consideration of my participation in the

, I acknowledge that I am aware of the possible RISKS, DANGERS AND HAZARDS

“club activity”

associated with the

, including the possible risk of severe or fatal injury to myself or others. The

activities carry many

inherent risks, which include but are not limited to the following:

risks associated with travel to and from all locations, venues and destinations of the various components including transportation provided by

public or private motor vehicle or hired service provider along with the hazards of being separated from my peers;

the possibility of physical injury to myself and other participants such as muscle strain, broken bones, concussion, soft tissue damage,

infectious diseases, cardiac arrest, through regular participation;

“club activity”

serious injury or death by failing to follow directions from those in charge of the

;

intoxication and/or alcohol poisoning from the alcohol I consume whether voluntarily or through coercion resulting in illness, injury or death;

medical problems arising before, during or after the planned activities;

the risks associated with returning to my residence once arriving back in Edmonton.

I freely accept and fully assume all such risks, dangers and hazard and the potential

of personal injury, death, permanent disability, property damage or loss resulting there of.

INITIALS_________

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom

of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of implementing this

waiver. Direct any questions about this collection to: the Office of the Dean of Students at 780-492-4145.

MEDICAL/HEALTH & TRAVEL INSURANCE

I AM SOLELY RESPONSIBLE to select and purchase adequate medical/health & travel insurance. No medical/health & travel insurance will be provided

by the Club. In the event of a medical/health problem, the Club accepts no responsibility for any costs associated with a medical/health problem nor will

they pay for any medical/health expenses, which may be incurred by the participant.

INITIALS_________

OFFICE OF THE DEAN OF STUDENTS

1 OF 2

June 2016

M:\SERM\Waivers\2016\Indian Students' Association\Annual Summer Trip, Jasper AB (July 2, 2016).doc