LIABILITY FORM 3 Special – Non-Staff/Non

LIABILITY FORM 3 Special – Non-Staff/Non-Student Participant
Liability Release and Assumption of Risk by Majority-Age Non-Student
for Field Trips and Other Off-Campus Activities
--------------------------------------------------------------------------------------------------------------------LIABILITY RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE
Release executed by
, whose address
[Full legal name of Participant]
is _______________________________________________ , to Austin Peay State
University, 601 College Street Clarksville, TN 37044.
I desire to participate in the following activity/trip
(ΑActivity≅), to be held at ___________________
___________________________________ , and I fully understand and appreciate the
dangers, hazards, and risks inherent in the Activity, in the transportation to and from the Activity,
and in any frolic, junket, independent excursion or task I undertake as an adjunct to the Activity,
which dangers include but are not limited
to_____________________________________________________________________ [if
necessary, described in more detail in the attached], and which also could include serious or
even mortal injuries and property damage.
Knowing the dangers, hazards, and risks of such activities, and in consideration of being
permitted to participate in the Activity, on behalf of myself, my family, heirs, and personal
representative(s), I, the undersigned, agree to assume all the risks and responsibilities
surrounding my participation in the Activity, the transportation to and from, and in any
independent research or activities undertaken as an adjunct thereto, and in advance release,
waive, forever discharge, and covenant not to sue the Institution, its governing board, officers,
agents, employees, and any students acting as employees (hereafter called the ΑReleasees≅),
from and against any and all liability for any harm, injury, damage, claims, demands, actions,
Liability: Form 3 (page 1 of 3)
causes of action, costs, and expenses of any nature that I may have or that may hereafter
accrue to me, arising out of or related to any loss, damage, or injury, including but not limited to
suffering and death, that may be sustained by me or by any property belonging to me, whether
caused by the negligence or carelessness of the Releasees, or otherwise, while in, on, upon, or
in transit to or from the premises where the Activity, or any adjunct to the Activity, occurs or is
being conducted.
I understand and agree that Releasees will not have medical personnel available during
the Activity. I understand and agree that Releasees are granted permission to authorize
emergency medical treatment, if necessary, and that such action by Releasees shall be subject
to the terms of this Agreement. I understand and agree that Releasees assume no
responsibility for any injury or damage which might arise out of or in connection with such
authorized emergency medical treatment.
It is my express intent that this release and hold harmless agreement shall bind the
members of my family and spouse, if I am alive, and my estate, family, heirs, administrators,
personal representatives, or assigns, if I am deceased, and shall be deemed as a ΑRelease,
Waiver, Discharge and Covenant≅ not to sue the above-named Releasees. I further agree to
save and hold harmless, indemnify, and defend Releasees from any claim by me or my family,
arising out of my participation ________________________________________
In signing this Release, I acknowledge and represent that I have fully informed myself of
the content of the foregoing waiver of liability and hold harmless agreement by reading it before
I sign it, and I understand that I sign this document as my own free act and deed; no oral
representations, statements, or inducements, apart from the foregoing written statement, have
been made. I understand that the Institution does not require me to participate in this activity,
but I want to do so, despite the possible dangers and risks and despite this Release. I further
state that I am at least eighteen (18) years of age and fully competent to sign this Agreement;
and that I execute this release for full, adequate, and complete consideration fully intending to
be bound by the same. I further state that there are no health-related reasons or problems
which preclude or restrict my participation in this activity, and that I have adequate health
insurance necessary to provide for and pay any medical costs that may be attendant as a result
of sickness or injury to me and that Releasees shall have no responsibility for the payment of
Liability: Form 3 (page 2 of 3)
I further agree that this Release shall be construed in accordance with the laws of the
State of Tennessee. If any term or provision of this Release shall be held illegal,
unenforceable, or in conflict with any law governing this Release the validity of the
remaining portions shall not be affected thereby.
I agree that my signature denotes my affirmation that I will abide by all state, local and
federal laws as well as all APSU Policies and Procedures.
IN WITNESS WHEREOF, I have executed this release this
, 20
day of
(Printed Name)
(Printed Name)
(Please print)
YOUR Name: __________________________________________________________
In case of emergency, contact _____________________________________ (name) who is
______________________________________________(relationship), at the
following number(s): _________________________________________________________.
Health Insurance Company Name ______________________________________________
Health Insurance Phone Number _______________________________________________
Policy Number ______________________________________________________________
Name of Insured ____________________________________________________________
Liability: Form 3 (page 3 of 3)