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Participant's name: ___________________________________________ Please Print

Summary: Participant's name: ___________________________________________
Please Print
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in
hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby
release, waive, discharge, and covenant not to sue The Regents of the University of California, its
officers, employees, and agents from liability from any and all claims including the negligence of
The Regents of the University of California, its officers, employees and agents, resulting in
personal injury, accidents or illnesses (including death), and property loss arising from, but not limited
to, participation in The Activity.
________________________________________ ________________________________
Signature of Parent/Guardian of Minor Date Signature of Participant Date
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be
eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to
another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major
injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3)
catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and
other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and


Source: Akhmedov, Azer - Department of Mathematics, University of California at Santa Barbara
Patel, Nipam H. - Department of Integrative Biology, University of California at Berkeley


Collections: Environmental Sciences and Ecology; Mathematics