WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
This document affects your legal rights. You should read and understand it before signing it.
In consideration for receiving permission to participate in Rec Sports Youth Camps
(describe activity)
on
Summer 2010
, I hereby waive, release, and discharge any and all claims for
(activity/trip date(s)
damages for death, personal injury or property damage which I may have or which hereafter may accrue to me
against the CSU, Chico Research Foundation, its programs, the State of California, the Trustees of the
California State University, and the officers and employees, as a result of my participation in any way in the
event described above.
This release is intended to discharge The State of California, Trustees of The California State University,
California State University, Chico, the CSU, Chico Research Foundation, officers, employees, students, and
volunteers of each and any other public agency from and against any and all liability arising out of or connected
in any way with my participation in the event/activity, even though that liability may arise out of the negligence
or carelessness on the part of persons or agencies mentions above.
I further understand that accidents and injuries can arise out of participation in this event/activity; knowing the
risks, nevertheless, I hereby agree to assume those risks and to release and to hold harmless all of the persons or
agencies mentioned above who (through negligence or carelessness) might otherwise be liable to me (or my
heirs or assigns) for damages. It is further understood and agreed that this waiver, release and assumption of
risk is to be binding on my heirs and assigns.
In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold
Harmless Agreement, understand it, and sign it voluntarily as my own free act and deed; no oral representations,
statements, or inducements, apart from the foregoing written agreement, have been made.
______As parent/guardian, I certify that he/she is in excellent health and has no physical, mental or emotional
problems which are likely to prevent participation in strenuous physical activity. I give permission for him/her
to be medically treated for illness occurring or injury sustained during participation in the above activity, and
certify that he/she is covered by medical insurance. I execute this Release for full, adequate and complete
consideration fully intending to be bound by same.
____________________________________
_________________________________________
Name of participant (print)
Signature of participant or guardian if under 18
___________________________________________________________________________________________
Street Address
City
State
Zip
_______________________
Phone
WITNESS:
_______________________________
Printed Name of Witness
____________
Date
___________________________________
Signature of Witness
CSU, CHICO RESEARCH FOUNDATION
AUTHORIZATION TO TREAT A MINOR
In the event that my son/daughter becomes ill or sustains an injury while in the care or under the supervision of
the
Rec Sports Youth Camps
program (name of program), operated through
the CSU, Chico Research Foundation, any of the adult supervisors of the activity is given my permission to administer
first aid for his/her relief.
If it is not practical to return him/her to me or to receive my instructions for his/her care:
I, the undersigned parent or legal guardian of __________________________________________, a minor, do hereby
authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and emergency
hospital care, which is deemed advisable by and is rendered under the general or special supervision of any member of the
medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act and on the staff of any
acute general hospital holding a current license to operate a hospital from the State of California Department of Health. It
is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any
of the above treatment will not be withheld if the undersigned cannot be reached.
This authorization is given pursuant to provision of Section25.8 of the Civil Code of California.
I further agree to not hold the above-named program or the CSU, Chico Research Foundation liable for the
medical aid rendered and will make reimbursement for the medical or other expenses incurred for the care of the named
minor.
Parent/Legal Guardian Signature:_______________________________________Date:________________________
Relationship to Minor:____________________________________________________________________________
Medical Insurance Information:
Name of Insurance Company:__________________________________________Policy #: _____________________
Name of Insured:____________________________________________________
Medical Information:
Allergies to drugs or foods:______________________________________________________________________
Required medications & frequency:_______________________________________________________________
Date of last Tetanus Booster:____________________________________________________________________
Are there any activity limitations or special needs?:___________________________________________________
____________________________________________________________________________________________
Any previous illness/injury that should be taken into consideration?______________________________________
Emergency Contact and Pick Up Information:
Name:_________________________ Phone #:_____________________ Relationship:_______________________
In the event a parent/guardian cannot be reached, please indicate relatives or family friends who may be contacted in an
emergency or for pick up.
Alternates:
Name:__________________________ Phone #:___________________ Relationship:______________________
Name:__________________________ Phone #:___________________ Relationship:______________________
Name:__________________________ Phone #:___________________ Relationship:______________________
CSU, Chico Research Foundation
INFORMED CONSENT AGREEMENT
This Agreement is to acknowledge that, in consideration of participation in the following
program:____Rec Sports Youth Camps_________________________
(name of program/description of activity)
to be held on:_______Summer 2010__________________________
(activity/trip date)
I consent to the following:
!
I understand that accidents and injuries can arise out of participation in activities such as
this. Knowing this, I am willing to assume the risk that an accident or injury may occur, and
agree to release the above parties from responsibility for risks associated with my
participation in the program.
!
I agree to release from liability and hold harmless the CSU, Chico Research Foundation, its
programs, the Trustees of the California State University, and their officers and employees,
from claims against them arising from injuries or property damage which might occur in
connection with this activity.
!
I certify that the participant is in good health and has the capacity to participate in programs
of this nature. I
!
I give permission for the participant to be medically treated for illness or injury occurring
during participation in the above activity, and certify that he/she is covered by medical
insurance. In the event that the participant is not covered by medical insurance, I agree
and accept responsibility for costs associated with medical treatment. A completed
“Authorization to Treat a Minor” form is attached.)
_______________________________
_______________________________
Name of participant (please print)
Signature of parent or guardian if under 18
____________________________________________________
Street Address
City
State
Zip
____________________
Phone
Permission to Publish Photos
On a Website or in Printed Materials
Photos of activities taken during the __Rec Sports Youth Camps________ (name of
camp) are important tools for publicizing and promoting future camps of this nature.
Permission from a minor and parent/guardian is required to allow this to occur.
To protect a child’s identity, names will not be published near or in reference to photographs. Only
the camp director or administrator will have permission to add pictures to the publicity materials or
website.
Camp Participant Consent
! YES ! NO
I give the CSU, Chico Research Foundation, CSU, Chico, and the CSU, Chico Recreational Sports
Department permission to use by photograph for reproduction on either website or in printed
materials for the sole purpose of publicizing the camp or for activities strictly related to the camp. I
understand that my name will not be associated with the photograph.
Date: __________________Camper Signature: _______________________________
Camper Printed Name: ___________________________
Parent/Guardian Consent
I am the parent or the legal guardian of the above-named minor and hereby approve the use of
her/his photograph pursuant to the terms described above.
I affirm that I have the legal right to issue such consent.
Date: __________________Parent/Guardian Signature: ________________________
Parent/Guardian Printed Name: _____________________
ASSOCIATED STUDENTS, INC
FOREBAY AQUATIC CENTER STATEMENT OF RISKS, ASSUMPTION OF RISKS AND LIABILITY RELEASE
Name of Outing: Rec Sports Youth Camps
Date of Outing:
Summer 2010
NAME: ________________________________________________ Phone # ___________________________________________
ADDRESS: ____________________________________________________________________________________________________
STREET
CITY
STATE
ZIP
Health & Accident Insurance Co. ________________________________Policy # ___________________________________________
Medical problems or allergic reactions: _____________________________________________________________________________
Medications currently taking: _____________________________________________________________________________________
Emergency Phone _______________________________________________________________________________________________
STATEMENT OF RISKS AND RESPONSIBILITIES:
The material in this section is provided for your general information. Be sure to check the attachments to this form, if any, which
describe specific risks and responsibilities associated with the particular activity in which you may be engaged.
GENERAL RISKS:
Please understand that when you participate in recreational activities in the indoors or outdoors, you are risking your physical being.
It is impossible, however, to list all the dangers involved in any activity. The eventualities of injuries, death, or property damage are so
diverse that no one can anticipate everything that can go wrong. Before you participate, you should become informed, as much as
possible, about the inherent dangers associated with the particular activity in which you are to be engaged. Also, you should make
sure that you are adequately prepared with the proper skills, equipment, and clothing to minimize these dangers. Here are only some
of these possibilities:
You can become ill or die from: polluted drinking water; improperly washed eating utensils; snake, insect, or animal bites;
exposure to heat or cold; personal health complications, e.g., strokes, appendicitis, heart attack.
You can also sustain injuries (sprained ankles, deep cuts, blisters, and other wounds) or die from: boating accidents; slipping off
wet or mossy boulders or trees; being submerged in frigid water, colliding with a vehicle, boat, rock, log, or tree; being hit by
lightening; hit by the boom of a sailboat; being bit by rattle snakes or other wildlife; falling and receiving injuries from sailing
equipment, such as the mast, boom, rope (lines), and sail; becoming entrapped in a kayak, sailboat, pedal boat, hydro bike, or
canoe; over exposure to the sun; receiving burns from hot fires, gas stoves, or other instruments; falling into the lake and
drowning; flipping boats; as well as many other possibilities.
Recognize that some outdoor activities take place far away from medical attention. Rescue, if possible, is often difficult and
expensive. If you must be rescued, you will be expected to bear the costs of the rescue. Recognize also that injuries, death, and
property damage may occur while rescue efforts are in progress.
Therefore, please do not participate in this activity if you think it is perfectly safe. It is not! You and your fellow companions are
expected to use common sense to reduce risk for yourself and to others.
Personal Medical Conditions: It is your responsibility to check with a medical doctor to see if you have any medical or physical
conditions which might create a risk to yourself or to others who would depend on you during this outing. These conditions may
include, but are not limited to, the following: physical or medical disabilities; medication or drugs you may be taking; dietary
restrictions; allergies or sensitivities to penicillin, insects, bees, poison oak, dust, foods, etc. You should discuss any potential problems
with the activity leader prior to the outing.
Use of Motor Vehicles and Insurance: Participating in this activity may involve the use of motor vehicles. If you drive or provide
your own motor vehicle for transportation to or from the program site, you are responsible for your own acts and for the safety and
security of your vehicle and those who ride with you. You must accept full responsibility for the liability of yourself and your
passengers. You are not covered by insurance through California State University, Chico or the Associated Students. Associated
Students does not insure personal property from damage or theft.
Riding as a passenger: If you are a passenger in a private vehicle, you should understand that the California State University, Chico,
the Associated Students, and Associated Students personnel, or volunteers are not in any way responsible for your safety during this
outing. Further, recognize that Associated Students insurance does not cover any damage, theft, or injury suffered in the course of
traveling in private vehicles.
Obligation regarding own medical insurance: No personal medical insurance is provided. It is your responsibility to obtain proper
personal medical and injury insurance.
Participation in this activity is voluntary: Forebay Aquatic Centers’ activities are not required, nor is any specific activity within an
outing required. If you feel a particular part of the outing is beyond your ability or if you feel it has some risks you are not prepared to
accept, you should simply feel free not to participate in that aspect of the activity. It is your responsibility, however, to constantly
evaluate outing activities and your ability to safely participate in such and make careful decisions whether or not you should
participate. You participate at your own risk. Alcohol and drugs and are not permitted during any activity put on by the Forebay
Aquatic Center.
You are responsible: In order for this outing to be enjoyable, it means that you need to take on some very important responsibilities.
These responsibilities, in part, include: taking care of personal medical and insurance concerns prior to participating, realistically and
honestly evaluating your abilities, and helping in any way possible to make the outing or activity enjoyable for you and others.
Initial___________
ASSUMPTION OF RISKS:
By signing and initialing as appropriate, you are agreeing to the following:
I have read the foregoing statement of risks together with any attachments associated with this outing and I acknowledge that I am
acquainted with the dangers and risks of this outing. Also, I am of the appropriate skill level and physical condition to undertake the
rigors of this class or outing. If I have any doubts of my physical or mental condition, I will seek medical advice. I have made a careful
decision that I am willing to accept and assume all risks. Initial: _________
LIABILITY RELEASE:
For the Associated Students permitting me to participate in the above-stated event, activity, or class, I understand and agree that
situations may arise during the event which may go beyond the control of the Associated Students or of outing guides or other
program participants. For myself and my personal representatives, assignees, heirs, and next of kin, or any of them, I AGREE TO
INDEMNIFY AND HOLD HARMLESS, RELEASE, FOREVER DISCHARGE, AND AGREE NOT TO SUE the State of California, the
Board of Trustees of California State University, California State University, Chico, the Associated Students of California State
University, Chico, and their officers, employees, volunteers, agents, and other outing members (collectively "releasees") from any and
all claims and liability arising out of strict liability or ordinary negligence of releasees which causes the undersigned injury, death, or
property damage. If I file suit it will be in Butte County, CA, and if the suit is unsuccessful I agree to pay court costs and attorneys' fees
for the defendants. I HEREBY WAIVE ALL SUCH CLAIMS WHICH I NOW OR MAY HEREAFTER HAVE AGAINST THE ABOVE
ORGANIZATION OR PERSONS. I have read and understood the above and agree to be bound by it. Initial: _________
IMPORTANT NOTE: BEFORE SIGNING, READ CAREFULLY THE STATEMENTS ON THE FRONT AND BACK OF THIS PAPER.
DO NOT SIGN-UP UNTIL YOU FULLY UNDERSTAND THIS STATEMENT AND THE RISKS ASSOCIATED WITH THIS OUTING.
IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK AT THE FOREBAY AQUATIC CENTER OFFICE,
LOCATED AT THE THERMALITO NORTH FOREBAY STATE PARK IN OROVILLE, PHONE #624-6919.
I HAVE READ CAREFULLY THIS FORM AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE
OF LIABILITY, A WAIVER OF CLAIMS, AN AGREEMENT NOT TO SUE, AND A CONTRACT BETWEEN MYSELF AND THE
ASSOCIATED STUDENTS, AMONG OTHERS, AND FOR MYSELF AND FOR THE BENEFIT OF OTHERS DESCRIBED HEREIN, I
SIGN IT OF MY OWN FREE WILL.
Signature:___________________________________________________________________Date_____________________________
REFUND POLICY: No refunds will be given unless you call in and we are able to fill your spot. Keep your receipt.