The Catholic University of America

Assumption of Risk and Liability Release

After reviewing this form, please fill out all information and place your signature where required, authorizing your participation in the _________________ program at/through The Catholic University of America.

PLEASE PRINT

Student's Name____________________________________________________

Address__________________________________________________________

City_____________________________ Zip Code_______________

Home Phone______________________ Local Phone(s)

I, __________________________assume the risks of personal injury and/or property damage in participating in the Program of _______________________ ("Program") at The Catholic University of America ("CUA"). I understand that any violation of campus rules may result in termination of my attendance in the program and/or judicial charges.

I understand that students will leave CUA campus during this Program and that I may travel in a university owned or a personal vehicle. I understand that if CUA is not providing a university owned or leased vehicle, and transportation consists of a personal vehicle (of another student, faculty or staff member) or public transportation, CUA has no liability regarding transportation and I travel at my own risk.

I hereby release any and all rights for claims and damages I may have against CUA, its trustees, officers, employees and agents, including faculty, staff members and supervisors, in any manner due to any personal injury or property loss sustained by me as a result of my traveling to and from the field trip destination(s) and/or my participation in the activities associated with the field trip, including any activities I may engage in during my free time while participating on the field trip. I will not hold CUA responsible for liability for injury or damages arising from the result of my participation in this Program unless it is due to willful or intentional misconduct or negligence on the part of CUA.

I hereby give permission for the faculty or staff member coordinating the trip to authorize emergency medical care on my behalf, if necessary, while participating in the Program.

I am fully qualified to meet the academic and technical requirements necessary to participate in this program. I am at least 18 years old and I enter this agreement voluntarily.

Student Signature________________________________Date____________________

* * * * * * * * * * * * * * *

Signature of Parent/Guardian if student is not at least 18 years old:

Signature_______________________________________Date____________________

Parent's Name___________________________________________________________

Parent's Telephone Number ________________________________________________

Parent's Address_________________________________________________________

NOTE: If you currently have a condition, i.e. medical, disability or other issue that will require accommodation in order to participate in this program, please contact Disability Support Services for disability related issues, and the faculty member sponsoring the trip for any other issues, in order to ensure that accommodations can be made in order for you to be able to participate fully. The University will make every effort to make the trip fully accessible. However, some elements may be out of the control of CUA and therefore, alternative options should be discussed with DSS and/or the faculty member leading the trip.




 

updated 12-7-15