Hold Harmless Form

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

 

 

I, ______________________________________ (print name), age _______, desire to participate in the Harry Nohr Woodturners Club at the University of Wisconsin – Platteville. 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: University Risk Management, at telephone number: 608-342-1188.

 

  Assumption of Risks: 

 

 I understand that physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of     the care taken to avoid injuries.  I am aware of the risks of participation.  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.

 

 Signature:  _________________________________________________ Date: ______________________

 

 Signature of Parent or Guardian

 (If Participant is under 18*): __________________________________Date: ______________________

 

 Hold Harmless, Indemnity and Release: 

 

 In consideration of permission for me to voluntarily participate in the above-mentioned activities, I, for myself, spouse, my 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-Platteville, 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 death which may result from my participation in the above-listed program.  This   release includes claims based on the negligence of the Board of Regents of the University of Wisconsin System, the University of   Wisconsin-Platteville, 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. 

 

 Signature:  _________________________________________________ Date: ______________________

 

 Signature of Parent or Guardian

 (If Participant is under 18*): __________________________________Date: ______________________

 

 Consent for Emergency Treatment: 

 

 I authorize the University of Wisconsin-Platteville 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.

 

 Signature:  _________________________________________________Date: ______________________

 

 Signature of Parent or Guardian

 (If Participant is under 18*): __________________________________Date: ______________________

 

 *If your son, daughter or ward will be under 18 while participating in recreational activities at the University of Wisconsin –   Platteville, it is our policy to request your agreement to the above terms, on behalf of your minor son, daughter or ward.