Community Service

Agreement for Assumption of Risk, Indemnification, Release, and Consent for Emergency Treatment

    I desire to participate voluntarily in the University of Wisconsin - Whitewater's Make a "Difference Day" within the City of Whitewater on April 19, 2013.

    I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT: DIRECTOR OF RISK MANAGEMENT & SAFETY, UW-WHITEWATER, RISK MANAGEMENT & SAFETY OFFICE, AT TELEPHONE NUMBER: (262) 472-5723.

  • Signature:_______________________________Date:_____________________

    ASSUMPTION OF RISKS:

    I understand that not all risks can be foreseen and there are some risks which are unpredictable. I understand that certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I am aware of the risks of participation, which include, but are not limited to, the possibility of physical injury, fatigue, bruises, contusions, broken bones, concussion, paralysis, and even death. I understand that the university has advised me to seek the advice of my physician before participating in the above named program. I understand that I have been advised to have health and accident insurance in effect and that no such coverage is provided for me by the University or the State of Wisconsin. I know, understand, and appreciate the risks that are inherent in the above-listed programs and activities. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

  • HOLD HARMLESS, INDEMNITY AND RELEASE:

    In consideration of my participation in these activities, I, for myself, spouse, heirs, personal representatives, estate or assigns, agree to defend, hold harmless, indemnify and release the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Whitewater, and their officers, employees, agents, volunteers, and all others who are involved, from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or dea th which may result from my participation in the above named program. This release includes claims based on the negligence of the Board of Regents of the University of Wisconsin System, the University of Wisconsin-Whitewater, and their officers, employees, agents, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence. I understand that by agreeing to this clause I am releasing claims and giving up substantial rights, including my right to sue.

  • CONSENT FOR EMERGENCY TREATMENT:

    I authorize the University of Wisconsin-Whitewater and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.

  • * If your son, daughter or ward will be under 18 while participating in the above named program, it is our policy to request your agreement to the above terms, on behalf of your minor son, daughter or ward.