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SOUTHERNCONNECTICUTSTATEUNIVERSITY New Haven Connecticut06515-1355 STATEMENT OF DUE WARNING AND ASSUMPTION OF RISK FORM Print or Type Information I being eighteen 18 years of age or older voluntarily agree to participate in the following activity please list specifics On the following date s With the following class/group/organization I am aware of the inherent and/or latent danger including but not limited to risk of serious injury the hazards of travel accident or illness or acts of God of participating in such an activity. I am aware that I should if appropriate have a medical exam prior to participating in this activity to ensure that I am in good physical health. I am aware that I should see that I am properly covered by adequate accident and/or medical insurance. If I am not I agree to obtain sufficient liability/accident/health/travel insurance at my own expense to insure me against any loss occasioned by this activity. I am also aware and have been advised that the University and/or its personnel will provide minimal or no supervision during this activity. Knowing this I assume all risks that may arise from or in connection with this activity. In addition I do hereby agree and warrant to release and hold harmless the State of Connecticut Board of Trustees of the Connecticut State University and/or Southern Connecticut State University its agents and employees from any and all liability claims demands actions and causes of action whatsoever arising out of or related to any loss damage or injury resulting from my voluntary participation in this activity. Individual s Name Student ID Local Telephone Local Address Emergency Contact Info Name Day Phone Evening Phone Signature Date Forms must be submitted to the Office of Student Life Michael J* Adanti Student Center Room 213 prior to the activity taking place. I am aware that I should if appropriate have a medical exam prior to participating in this activity to ensure that I am in good physical health. I am aware that I should see that I am properly covered by adequate accident and/or medical insurance. I am aware that I should see that I am properly covered by adequate accident and/or medical insurance. If I am not I agree to obtain sufficient liability/accident/health/travel insurance at my own expense to insure me against any loss occasioned by this activity. If I am not I agree to obtain sufficient liability/accident/health/travel insurance at my own expense to insure me against any loss occasioned by this activity. I am also aware and have been advised that the University and/or its personnel will provide minimal or no supervision during this activity. I am also aware and have been advised that the University and/or its personnel will provide minimal or no supervision during this activity. Knowing this I assume all risks that may arise from or in connection with this activity. In addition I do hereby agree and warrant to release and hold harmless the State of Connecticut Board of Trustees of the Connecticut State University and/or Southern Connecticut State University its agents and employees from any and all liability claims demands actions and causes of action whatsoever arising out of or related to any loss damage or injury resulting from my voluntary participation in this activity.

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Keywords relevant to Assumption Of Risk Form

  • inherent
  • Hazards
  • LATENT
  • insure
  • trustees
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