Download WAIVER& RELEASE OF LIABILITY, & COVENANT NOT TO SUE

WAIVER& RELEASE OF LIABILITY,
& COVENANT NOT TO SUE
(BINDING LEGAL DOCUMENT — READ CAREFULLY BEFORE SIGNING)
I hereby acknowledge that my participation iQ(QJLQHHULQJ6XPPHU&DPS at the6FKRRORI(QJLQHHULQJ,
hereinafter “Activity,” sponsored and administered by Southern Illinois University Edwardsville’s
on, 2016, involves an inherent risk of and exposure to property damage and bodily or
personal injury to myself or to others. Dangers related to such activities may include but are not
limited to: hypothermia, broken bones, strains, sprains, bruises, drowning, concussion, heart attack,
heat exhaustion, injuries associated with travel, and death. I acknowledge that I am aware that there
are risks, hazards, and dangers inherent in the Activity and in the training, preparation for, and travel
to and from the Activity. I further acknowledge that it is my sole responsibility to participate only in
those activities for which I have the prerequisite skills, qualifications, preparations, and training. I
acknowledge that the Board of Trustees of Southern Illinois University governing Southern Illinois
University Edwardsville and its members individually, and its officers, agents, and employees
(hereinafter SIUE) do not warrant or guarantee in any respect the competency or mental or physical
condition of any third party affiliated with the Activity, including third party leaders, instructors,
vehicle drivers, or individual participants in the Activity. I further acknowledge that SIUE makes no
warranty as to the condition, safety, or suitability of any equipment, vehicle, property, or premises
for any purpose. I acknowledge that I am solely responsible, through insurance or otherwise, for any
hospital or other costs arising out of any bodily injury or property damage sustained through my
participation in the Activity. I hereby assume any and all such risk. I acknowledge that SIUE does
not provide insurance coverage for me. For the sole consideration of SIUE arranging for and
allowing my participation in the Activity, and in connection therewith, making available for my use
while participating in the Activity, certain equipment, facilities, grounds, or personnel of SIUE, I
hereby waive liability, release, and forever discharge for myself, my spouse, if applicable, my heirs,
executors, administrators and assigns, agrees to waive liability, release, hold harmless, covenant not
to sue, and forever discharge SIUE from any and all liability, claims, demands, rights, and causes of
action of whatever kind, arising from or by reason of any personal injury, property damage, or the
consequences thereof, resulting from or in any way connected with this Activity whether caused by
the ordinary, active or passive negligence of SIUE or otherwise, to the fullest extent provided by law.
I understand that acceptance of this signed Waiver & Release of Liability & Covenant Not To Sue
Agreement by SIUE shall not constitute a waiver, in whole or in part, of sovereign immunity, if any,
by SIUE. I further understand and agree that this Release, Waiver of Liability, Assumption of Risk,
& Covenant Not To Sue Agreement shall be effective during the entire period of my participation in
the Activity and that it binds me and my heirs, executors, administrators, and assigns, as well as
myself.
I have read, understand, and have freely and voluntarily signed this Waiver & Release of
Liability & Covenant Not To Sue Agreement.
This the ___________ day of _________________ , 2016.
Signature of Participant
Signature of Witness (Must be 18 years or older)
_____________________________________
________________________________
Date: ________________________________
Date: ___________________________
SUMMER ACTIVITIES FOR YOUTH
HEALTH INFORMATION AND CONSENT FORM
To be completed by the participant’s PARENTS. Please return with camp
application.
1.
2.
Engineering Summer Camp, Session 1
Camp or Program
4.
5.
6/5 - 6/10, 2016
Participant’s Name
(last)
3.
Dates
Home Address
and Phone:
(street or route)
Parent’s Names: Mother (or
Guardian)
Work Address
and Phone:
(first)
(middle)
(city or town)
(state)
(zip)
(phone)
(last)
(first)
(middle)
Father (or
Guardian)
(last)
(first)
(middle)
Mother (or
Guardian)
(place)
(city or town)
Father (or
Guardian)
(street or route)
(state)
(place)
(city or town)
(zip)
(phone)
(street or route)
(state)
(zip)
(phone)
6.
Please list a close relative or friend who may be contacted if you are unavailable in case of an emergency:
7.
Is there any information regarding your child of which the camp staff and faculty should be aware? Please check and explain.
Handicapping conditions
Diseases
Allergies
Activity restriction
Necessary regular medications
Other
8.
Physician to be contacted in case of emergency:
Name
Telephone Number
Address
Your signature indicates parental approval of the student’s attendance at and participation in all camp activities except as noted by you in
number 7 above.
(Signature of parent or guardian)
(date)
Consent of Treatment----------------------------------------------------------------------------------------------I hereby authorize the Southern Illinois University Edwardsville to provide or obtain emergency medical care for
, a minor. I understand that I will be responsible for any charges incurred for such care.
Signature
Telephone
(Parent or Guardian, if patient is under 18 years of age)
Relationship to Minor
Distribution:
Program Director
/
Program Staff
PHOTOGRAPH / VIDEO CONSENT AND RELEASE (ADULT)
I, (print name) ___________________________________________, hereby consent and grant
permission to the Board of Trustees of Southern Illinois University Governing Southern Illinois
University Edwardsville, its employees, and representatives (collectively SIUE) to take and use
photographs, videotapes, digital images, or otherwise recorded images of me and to publish such images
or depictions for promotional, marketing, or educational purposes in any form, including, but not limited
to print, electronic, video, or Internet. I also hereby consent and grant permission to SIUE to edit, crop,
retouch, or otherwise alter such images or depictions, I waive any privilege to inspect such images or
depictions prior to publication, and I authorize the use of these images indefinitely without compensation
to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of SIUE.
SIUE may ___ may not ___ (check one) use my name and identity in connection with the image.
______________________________________
(Date)
______________________________________
(Signature of adult subject)
______________________________________
(Address)
______________________________________
(City, State, ZIP)
************************************************************************************
PHOTOGRAPH / VIDEO CONSENT AND RELEASE (CHILD)
I, (print name)___________________________________________, parent or official guardian of
(child’s name)____________________________________________hereby consent and grant permission
to the Board of Trustees of Southern Illinois University Governing Southern Illinois University
Edwardsville, its employees, and representatives (collectively SIUE) to take and use photographs,
videotapes, digital images, or otherwise recorded images of my child and to publish such images or
depictions for promotional, marketing, or educational purposes in any form, including, but not limited to
print, electronic, video, or Internet. I also hereby consent and grant permission to SIUE to edit, crop,
retouch, or otherwise alter such images or depictions of my child, I waive any privilege to inspect such
images or depictions prior to publication, and I authorize the use of these images indefinitely without
compensation to me or my child. All negatives, positives, prints, digital reproductions and videotape shall
be the property of SIUE.
SIUE may ___ may not ___ (check one) use my child’s name and identity in connection with the image.
______________________________________
(Date)
______________________________________
(Signature of parent or guardian)
______________________________________
(Address)
______________________________________
(City, State, ZIP)
CAMPER INPUT
We have a few final decisions for you so that we can make your experience with the School of
Engineering as convenient and fun as possible. Please look over the options below and return
this sheet in the envelope provided.
PARKING PERMIT
Those campers who will be driving to camp should obtain a parking permit to allow them to park
in the residence hall lot.
Car Owner:
Car Make &
Model:
License
Plate:
Camper
Driver’s
License #:
SANDWICH LUNCH
Most of the campers’ meals will be eaten in the Morris University Center as part of the college
experience. A boxed lunch will be provided for the day we have industry professionals join
campers for lunch. Please indicate your sandwich preference below with an ‘X’.
Beef
Ham
Turkey
Vegetarian
T-SHIRT SIZE
Each camper gets an engineering camp t-shirt. Please let us know which adult size to order.
Name: