I, (print name), age
, desire to participate voluntarily in recreational, service, and/or
travel activities at the University of Wisconsin – Stevens Point and through
(organization name) during the period of September
2011 through May 2012.
I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF
THE FOLLOWING PARAGRAPHS CAREFULLY.
I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS
AGREEMENT, I MAY CONTACT: Jeff Karcher, Campus Risk Manager, AT TELEPHONE NUMBER
715-346-3901.
Assumption of Risks:
I understand that physical
activity and participation related to
(organization) activities, by its very nature, carries with it certain inherent
risks that cannot be eliminated regardless of the care taken to avoid injuries.
Some of these involve strenuous exertions of strength using various muscle
groups, some involve quick movement involving speed and change of direction,
others involve sustained physical activity, which places stress on the
cardiovascular system and some involved mild activity.
The specific risks vary from one activity to another, but in each
activity the risks range from: 1)
minor injuries such as scratches, bruises, and sprains to 2) major injuries such
as fractures, internal injuries, joint or back injuries, heart attacks, and
concussions to 3) catastrophic injuries including paralysis and death.
I understand that the University has advised me to seek the advice of my
physician before participating in this activity.
I understand that I have been advised to have health and accident
insurance in effect and that no such coverage is provided for my by the
University or the State of
Signature of Parent or
Guardian
(if Participant is Under
18):
Date:
Hold
Harmless, Indemnity and Release:
In consideration of permission for me to voluntarily
participate in (organization) activities, today
and on all future dates, I, for myself, my heirs, personal representatives or
assigns, agree to defend, hold
harmless, indemnify and release the Board of Regents of the University of
Wisconsin System, the University of Wisconsin- Stevens Point, and their
officers, employees, agents, and volunteers, from and against any and all
claims, demands, actions, or causes of action of any sort on account of damage
to personal property, or personal injury, or death which may result from my
participation in the above-listed program.
This release includes claims based on the negligence of the Board of
Regents of the University of Wisconsin System, the University of Wisconsin-
Stevens Point, and their officers, employees, agents, and volunteers, but
expressly does not include claims based on their intentional misconduct or gross
negligence.
I understand that by agreeing to this clause I am releasing claims and
giving up substantial rights, including my right to sue.
Signature of Parent or
Guardian
(if Participant is Under
18):
Date:
Conduct
I agree to conform to all applicable policies, rules, regulations and standards
of conduct as established by the University.
Additionally, I understand and agree that my participation in this
Program may be terminated by the University with no refund of fees if I fail to
maintain acceptable standards of conduct as established by the University and I
accept responsibility for the costs of returning home if I am terminated under
these circumstances.
Signature of Parent or
Guardian
(if Participant is Under
18):
Date:
Consent for Emergency
Treatment:
I authorize the University of Wisconsin – Stevens Point and its designated
representatives to consent, on my behalf, to any emergency medical/hospital care
or treatment to be rendered upon the advice of any licensed physician.
I agree to be responsible for all necessary charges incurred by any
hospitalization or treatment rendered pursuant to this authorization.
Signature of Parent or
Guardian
(if Participant is Under
18):
Date: