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Hold Harmless Information Form

Directions: Complete all of the information requested on this electronic form and click submit below. The Office of Environmental Health, Risk Management & Safety will prepare the Hold Harmless using the information you provide. Please try to keep responses as brief as possible. If you experience difficulty using this form or have any questions, please call 472-1856. Thank you.

**Please Note: This is for UW-Whitewater use only**



Type of Activity (Please give as much information as possible):

Location of Activity:

Date of Activity:


Sponsoring Organization or Department:

Contact Information(Required):

Name of Contact Person:
Campus Phone Number:
Dept/Office:
Local Email Address: