Dixie State University Waiver Release of Liability, Indemnification, and Consent to Medical Attention

 

Dixie State University Waiver Release of Liability, Indemnification, and Consent to Medical Attention

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This is a Waiver release of liability, Indemnification, and consent to medical attention. The Informed Consent Form for Minors, identifies risks of participating in DSU course or program, and a Waiver and Release for parents/guardians.

Injury may result from your participation in

You are expected to familiarize yourself with what is required, rules of conduct for the course/program as well as DSU policies. You are expected to follow proper operating procedures including safety procedures as outlined by the course/program instructor, plus any directions given by an authorized DSU employee.

I,

acknowledge that I have familiarized myself with

and what is required, will follow the rules of conduct, will follow the operating procedures, and will follow any directions given by an authorized school employee.

Signature of Student

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The undersigned, the legal guardian of

(hereinafter "student")

a student at Dixie State University under eighteen years of age, in consideration of student’s participation in the course/program of

do hereby agree to this waiver and release.

I recognize that participation in this trip or activity may involve moderate to strenuous physical activity and may cause physical and or emotional distress to participants. There may also be associated health risks. I state that student is free from any known heart, respiratory or other health problems that could prevent student from safely participating in any of the activities.

I certify that I have medical insurance or otherwise agree to be personally responsible for costs of any emergency or other medical care that student receives. I agree to release State of Utah, DSU and their agencies, departments, officers, employees, agents, and all sponsors, officials and staff or volunteers from the cost of any medical care that student receives as a result of participation in

courses.

I further agree to release the State of Utah, DSU, their agencies, departments, officers, employees, agents and all sponsors, officials and staff or volunteers from any and all liability, claims, demands, breach of warranty, negligence, actions, and causes of actions whatsoever for any loss, claim, damage, injury, illness, attorney’s fees or harm of any kind or nature to me arising out of student’s participation in this DSU course/program. This release extends to any claim made by parents or guardians or their assigns arising from or in any way connected with the aforementioned activities.

CONSENT

Consent is expressly given, in the event of injury, for any emergency aid, anesthesia and / or operation, if in the opinion of the attending physician, such treatment is necessary.

I have carefully read and understand the contents of the foregoing language and I specifically intend it to cover student’s participation in the above stated field trip.

(Parent or legal guardian signature if participant is under 18 years old)