Fillable Risk And Release Form printable pdf download

RISK AND RELEASE FORM

PRINT CLEARLY & LEGIBLY:

Name of Club: ________________________________________________________________________

Name of Activity: ______________________________________________________________________

Date(s): __________________________________________Time: _______________________________

• I understand that my participation in this activity is voluntary and I am physically fit to participate.

• I agree fully understand the written safety and other rules and precautions that are part of the

requirements for my participation in the above referenced activity as well as those explained to me

by my advisor(s).

• I do for myself, my heirs, executors, and administrators accept full responsibility for the indemnity,

release, and discharge the University of Hawaii, its officers, agents, and employees from any and

all claims of actions for property damage and/or personal injury in which may result from my failure

to abide by these safety rules and precautions or from any inherent risk in said activity.

EMERGENCY CONTACT INFORMATION

NAME (PRINT): ________________________________________________________________________

PHYSICIAN’S NAME: _________________________ PHONE NUMBER: _______________________

MEDICAL INSURANCE (CHECK ONE OF THE FOLLOWING):

O My medical insurance carrier is: __________________________________________________

O I DO NOT HAVE medical insurance

IN CASE OF AN EMERGENCY PLEASE CONTACT THE FOLLOWING PERSON:

Name (Print):__________________________________ Relation: ___________________________

Home Phone Number: ______________________ Work Phone Number: _______________

MEDICAL CONSENT:

O Yes, we (I), __________________________, do consent to authorize any medical doctor, dentist or

others working under their supervision to treat ______________ for any injury or illness.

O No, we (I), __________________________, do not consent to or authorize any medical doctor,

dentist, or others working under their supervision to treat____________________ for any injury or

illness. Therefore, we (I) agree to assume the risk of any injury or damage from the lack of any

medical treatment and further agree to release, discharge and hold harmless the State of Hawaii,

its employees and agents from and against any liability and any claim or demand arising out of or

in connection with said failure to provide any medical care or treatment.

Name (Print): ___________________________________ Student ID #: _________________________

Signature: ________________________________________________ Date: ___________________

PARTICIPANT UNDER THE AGE OF 18 REQUIRES PARENT OR GUARDIAN’S SIGNATURE

Parent/Guardian Signature: ______________________________________ Date: __________________

Home Address: _________________________________ Phone Number: ________________________

__________________________________

Risk And Release Form