Assumption of Risk and Release Form 2016-2017

Assumption of Risk and Release
(Field Trips and Off-Campus Activities)
Please state your full name
Email address
Cell phone number
Name of Organization:
Please list the activity/event you are participating in
Where is this activity/event being held?
What is the date of the activity/event?
Name of insurance company
Policy number

In consideration of my participation in the Event, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release, discharge, and covenant not to sue, the University of Massachusetts Dartmouth (the “University”), and its Board of Trustees, officers, employees and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Event, whether caused by negligence of the University, its Board of Trustees, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the University and its Board of Trustees, officers, employees, and representatives from and against any and all claims, liability, damages, loses, or expenses (including attorney’s and expert’s fees) arising out of or resulting from the injury or death of any person(s) or damage to property that may result from my negligent or intentional act or omission while participating in the described Event. 

In case of emergency, please contact (Full name):
What is your relationship to this person?
Emergency Contact Phone number
Emergency Contact Address
If you are under eighteen (18) years of age, please list name of legal guardian