Release And Indemnification Agreement For Adult Participants
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1EXHIBIT B4-A
RELEASE AND INDEMNIFICATION AGREEMENT FOR ADULT PARTICIPANTS
ADULT PARTICIPANT: (Name and Address)
INSTITUTION:
__________________________________________
The University of Texas at Dallas (UTD)
Name (last name first - please print or type)
__________________________________________
__________________________________________
Address
(School/Administrative Division)
__________________________________________
__________________________________________
City, State, Zip Code
(Program/Administrative Unit)
Check here if you are not a registered UTD student.
IDENTIFYING DESCRIPTION OF ACTIVITY AND/OR TRAVEL: ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
MODE OF TRANSPORTATION: ___________________________________________________________
PRINCIPAL LOCATION(S): _________________________________________ DATE(S): _____________
I, the above named participant, am eighteen years of age or older and have voluntarily applied to participate in the
above Activity and/or Travel. I acknowledge that the nature of the Activity and/or Travel could possibly expose me to
hazards or risks that could result in my illness, personal injury or death and I understand and appreciate the nature of
such hazards and risks. I grant UTD and its employees full authority to take whatever actions they may consider to be
warranted under any circumstances regarding the protection of my health and safety. I understand and agree that if I
do not comply with all the rules, code of conduct, and instructions relating to this Activity and/or Travel, UTD has the
right to terminate my participation in this activity without refund.
In consideration of my participation in the Activity and/or Travel, I hereby accept all risk to my health and of my
injury or death that may result from such participation, including transportation and all other adjunct activities, and I
hereby release UTD, its governing board, officers, employees and representatives from any liability to me, my
personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or
damage to my property and for any and all illness or injury to my person, including my death, that may result from or
occur during my participation in the Activity and/or Travel, whether caused by any type of negligence of UTD, its
governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless
UTD and its governing board, officers, employees, and representatives from liability for the injury or death of any
person(s) and damage to property that may result from my negligent or intentional act or omission while participating
in the described Activity and/or Travel.
I
HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES
OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN
A
/
T
THE ABOVE DESCRIBED
CTIVITY AND
OR
RAVEL AND THAT IT OBLIGATES ME TO INDEMNIFY THE PARTIES
NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY
.
NEGLIGENT OR INTENTIONAL ACT OR OMISSION
THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE
,
WITH THE LAWS OF THE STATE OF TEXAS
WHICH SHALL BE THE FORUM FOR ANY LAWSUITS FILED UNDER OR
.
INCIDENT TO THIS AGREEMENT OR ACTIVITY
__________________________________________
__________________________________________
Signature of Adult Participant*
Date signed
__________________________________________
__________________________________________
Signature of Witness
Date signed
__________________________________________
Printed Name of Witness
March 2005
*S
-
A
/
T
.
IGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE
REFERENCED
CTIVITY AND
OR
RAVEL
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