Domestic Travel Release Form - Camping Fall 2013

Domestic Travel Release Form - Camping Fall 2013
Domestic Travel Waiver
Waiver of Liability and Conditions [Required]
In consideration for permitting me to participate in the activity described above, which will or may involve travel in, from, and to New York, New York, and in, to and from
other places, I hereby agree:
(a) to release and discharge New York University School of Medicine (the “University”) from any liability or responsibility for any injury (including death), and for any
damages to or loss of property, however caused, that I suffer as a result of or in conjunction with my participation in the activity or any travel related to the activity, including,
without being limited to, any injury, loss, or damage resulting from, arising out of or occurring in connection with the negligent acts or omissions of members of the faculty or
other employees or agents of the University and
(b) not to raise any claim or institute any legal action or proceeding against the University for any cause of action that may result from or arise out of or in connection with
my participation in the activity or any travel related to the activity, including, without being limited to, any cause of action that may result from or arise out of or in connection
with the negligent acts or omissions of the members of the faculty or other employees or agents of the University.
All references to the University in this form shall include, and all provisions of this firm shall insure to the benefit of, the University’s trustees, officers, employees, agents,
servants and representatives.
I will inform an appropriate representative of the school from the office indicated above of any special information regarding my health, or physical or mental condition that
may be relevant to my participation in the activity or any travel related to the activity.
This release shall be governed by and construed in accordance with the laws of the State of New York applicable to contracts entered into and intended to be performed
solely within the state indicated below. I shall submit to the jurisdiction of the federal and state courts located in New York County, New York State, for the resolution of the
disputes arising hereunder or relating hereto, regardless of the place of execution thereof.
Valid input:
- Select only one choice.
[ ] I Agree
Name of Activity [Required]
Starting date of activity [Required]
State in which the activity is taking place: [Required]
Ending date of activity [Required]
Emergency Contact Name [Required]
Relationship to Contact [Required]
Contact's Phone Number [Required]
Page 1 of 1 · Domestic Travel Release Form - Camping Fall 2013