Risk Assessment and Release Form

ADVERTISEMENT
Print Form
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
Print Form
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

Download Risk Assessment and Release Form

343 times
Rate
4.6(4.6 / 5) 21 votes
ADVERTISEMENT