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The University of Texas at Arlington

Form 15-13

Release and Indemnification Agreement for Minors

Rev. 04/01/2010

PARTICIPANT: (Name and Address)

__________________________________

DESCRIPTION OF ACTIVITY OR TRIP: ________________________________________________________

_____________________________________________________________________________________________

LOCATION: _______________________ DATE(s): ________________________

I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and am fully competent

to sign this Agreement.

I give permission for Participant to participate in the above-referenced Activity or Trip. I acknowledge that the

nature of the Activity or Trip may expose Participant to hazards or risks that may result in Participant's illness,

personal injury or death and I understand and appreciate the nature of such hazards and risks.

In consideration of Participant being permitted to participate in the Activity or Trip, I hereby accept all risk to

Participant's health and of his/her injury or death that may result from such participation and I hereby release the

above named Institution, its governing board, officers, employees and representatives from any and all liability to

Participant, Participant's personal representatives, estate, heirs, next of kin, and assigns for any and all claims and

causes of action for loss of or damage to Participant's property and for any and all illness or injury to Participant's

person, including his/her death, that may result from or occur during Participant's participation in the Activity or

Trip, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or

otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers,

employees, and representatives from liability for the injury or death of any person(s) and damage to property that

may result from Participant's negligent or intentional act or omission while participating in the described Activity or

Trip.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL

CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT'S INJURY OR DEATH OR DAMAGE TO

PARTICIPANT'S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED

ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY

LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY

PARTICIPANT'S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

__________________________________

Signature of Parent/Guardian

Signature of Witness

__________________________________

Date Signed

Address (if different than Participant's)

__________________________________

Date Signed

You may be entitled to know what information UT Arlington collects concerning you. You may review and have UT

Arlington correct this information according to procedures set forth in UT System Administration UTS139. The law is found

in sections 552.021, 552.023, and 559.004 of the Texas Government Code.

Release And Indemnification Agreement For Minors Template - The University Of Texas At Arlington