Participation, Waiver and Release of Liability Form - NDSU

UPSO-Waiver - REV 05/2011
Page 1 of 1
Participation, Waiver, and
Release of Liability Form
Questions about this form? Please call 701-231-7759
Return this completed form to the
sponsoring department.
Name:
Acknowledgement and Assumption of Risk
I am aware of the dangers and the risks to my person and property involved while participating in:
I understand that this activity involves certain risks for physical injury. I understand that equipment, if any, which may be provided for my
protection may be inadequate to prevent serious injury. I also understand that there are potential risks of which I may not presently be
aware.
Nevertheless, I voluntarily elect to participate in this activity/class with knowledge of the danger involved, and I hereby agree to
accept and assume any and all risks of property damage, personal injury, or death.
The University does not insure participants in the above-described activity and participants who want to be covered must obtain their
own insurance. The University asserts lack of responsibility or liability for injury resulting from this activity.
In consideration for being allowed to voluntarily participate in the above-referenced activity and or intramural event, on behalf of myself,
my personal representatives, heirs, next of kin, successors and assigns, I forever:
a. waive, release, and discharge the State of North Dakota, its agencies, officers, and employees from any and all negligence
and liability for my death, disability, personal injury, property damages, property theft or claims of any nature which may
hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or
event; and
b. defend, indemnify, and hold harmless the State of North Dakota, its agencies, officers and employees (State), from any
and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise
out of this agreement, except for claims resulting from or arising out of the State's sole negligence.
I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident or illness during
this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification,
and waiver to the maximum extent permissible under applicable law.
I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this
form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be
available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the
remainder will continue in full legal force and effect.
Waiver of Liability and Indemnification
Read Before Signing
Signature Date
Witness Signature Date
Witness Name:
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