Indiana Liability Release Form 2

INDIANA WESLEYAN UNIVERSITY FUSION 2013
VOLUNTARY RELEASE FROM LIABILITY AND ASSUMPTION OF RISKS (“Release”)
IMPORTANT NOTICE: BY SIGNING THIS DOCUMENT, YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE
INDIANA WESLEYAN UNIVERSITY (IWU). PLEASE READ CAREFULLY.
Name of Participant (please print): ________________________________________ Date of Birth: ____/____/_____
Phone Number: ____________________________
Emergency Contact: _____________________________________________ Relationship: ____________________
Phone Number: ____________________________
DISCLAIMER
Indiana Wesleyan University, its officers, directors, employees, volunteers, members and representatives (hereafter referred to as “the University”) are not responsible for
any injury, loss, or damage sustained by any person, which may result from or be related to participating in FUSION 2013 and all associated activities (hereafter referred
to as “Activities”), irrespective of the cause of such injury and whether such cause is alleged to be the fault of the University. Such Activities include, but are not limited to
swimming, diving, artificial climbing wall, inflatable games, walley-ball, soccer, basketball, dodgeball, racquetball, carpetball, running, jumping, sliding, walking and use
of related equipment.
ASSUMPTION OF RISKS
In consideration of my participation in these Activities, I acknowledge that I am aware of the risks of harm to myself and my property, both from
known risks and unanticipated risks, while participating in or traveling to or from the Activities. I participate in the Activities willingly, voluntarily and
in reliance, not upon the property, equipment, facilities and existing conditions furnished by the University or others, but upon my own judgment
and ability, and I thereby assume all risk of loss, damage or injury (including death) to myself and my property from any cause whatsoever and
whether or not attributable to the negligence of others.
These Activities involves inherent risks. These risks could result in bodily injury including burns, slips and falls, injury to muscles and joints, broken
bones, head or neck injuries, lost wages, loss of services, emotional distress, sickness, drowning, disease, dismemberment, death and any other
foreseen or unforeseen damages.
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INDEMNIFICATION AND RELEASE OF LIABILITY
In return for the University allowing me to voluntarily participate in these Activities, I agree:
1. TO FOREVER RELEASE, ACQUIT AND FOREVER
2. TO BE SOLELY RESPONSIBLE FOR ANY INJURY,
DISCHARGE AND RELEASE THE UNIVERSITY, AND
LOSS, OR DAMAGE which I might sustain while
TO ASSUME AND ACCEPT ALL RISKS arising out
participating in the Activities, even though such
of, associated with or related to my participating
injury, loss, or damage may have been alleged to
in the Activities, even though such risks may
have been caused by the actions of the University,
be alleged to have been caused by the actions,
including, but not limited to, negligence.
including negligence, of the University.
3. TO INDEMNIFY AND HOLD THE UNIVERSITY
FREE AND HARMLESS from any claims, actions,
causes of actions or demands of any kind asserted
by the undersigned or by any third parties for
any injuries or damages which may arise from
participating in the Activities.
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PARTICIPANT DECLARATIONS
I affirm that I have the requisite skills and abilities to safely participate in the Activities. I do hereby declare myself to be physically and mentally sound and suffering from
no condition, impairment, disease or other illness that would prevent or inhibit my participation in these Activities. Any equipment I supply is in good condition, order,
and repair, and is fit for and will be used for its intended purpose. If I believe that a materially unsafe condition exists, I will report the condition to an official, and cease
participation in the activity until that condition is resolved. I certify that I have adequate insurance to cover injury or damage, including damage to or loss of personal items,
that I may cause or suffer while participating in these Activities, or else I agree to bear the cost of such injury, damage or loss myself. I further certify that I am willing to
assume the risk of any medical or physical condition I may have. I consent to the provision of emergency medical treatment to the extent that the treatment is necessary in
the opinion of a medical professional.
ACKNOWLEDGMENT
I acknowledge that I have read this agreement, that I have executed this agreement voluntarily, and that this agreement is to be binding upon myself, my heirs, executors,
administrators and representatives in the event of my death or incapacity.
In consideration that the participant is a Minor, this Release remains in full force and effect and that by signing this Release, I affirm that I am the legal guardian of the Minor
and agree and consent to this Release on behalf of said Minor.
Signature of Participant (if 18 years of age or over)___________________________________________ Date_____________________________
Printed Name of Guardian/Parent (if Participant is under 18 years of age)___________________________________________________________
Signature of Guardian/Parent (if Participant is under 18 years of age)______________________________________________________________
2013 REGISTRATION Also available online at indwes.edu/studentministries
This registration is for: oStudent o Adult Sponsor
(CHECK ONE)
Male
Name__________________________________________________________________________ o
oFemale
Address____________________________________________________________________________________________
City______________________________________________State______________ Zip__________________________
Phone ( ____________ ) ______________________________________________________________________________
E-mail______________________________________________________________________________________________
High School________________________________________ Graduation Year ___________________________________
Church/Group_______________________________________________________________________________________
Nickname___________________________________________________________________________________________
(please provide or create a name that will help us identify your group, e.g., Surge, United, The Well)
Contact Person_______________________________________________________________________________________
Daytime/Work (
)____________________________________ Mobile (
)__________________________________
E-mail_____________________________________________________________________________________________
Group overnight Housing Plans (Check one)
o On Campus (Students and sponsors stay with IWU student hosts in residence halls. Remember to bring a
sleeping bag and pillow.)
Roommate preference ______________________________________________________________________________
o Other/Area Hotel (Sponsor must make own arrangements for group. See website for listing.)
Please Note
• Please copy this form, as needed, for additional registrations. Submit registrations as a group. Online
registrations are preferred.
• Sponsors are needed for both male and female students. There must be one male sponsor for every 10 male
students and one female sponsor for every 10 female students.
• Groups must submit forms together to be housed together. All housing assignments will be final upon check-in.
• Cost is $55 per registration. Final payment due upon arrival.
(Checks payable to Indiana Wesleyan University)
• March 21, 2013, is the registration deadline.
student ministries
4201 south washington street
Marion, INdiana 4 6 9 5 3 - 4 974
indwes.edu
Questions? 866-468-6498 / 765-677-2036 / [email protected]
THE RELEASE OF LIABILITY FORM ON THE REVERSE SIDE MUST BE COMPLETED