RELEASE AND INDEMNITY AGREEMENT
I, ___________________________________(Please Print), a student,
faculty, staff member at North Carolina Wesleyan College, hereby expressly
acknowledge that, as part of my education at North Carolina Wesleyan
College, I may take part in certain activities outside the classroom which may
expose me to certain dangers inherent in such activities.
In consideration for North Carolina Wesleyan's making such
opportunities available to me, I, for myself, my heirs, personal representatives
and assigns, do hereby release and forever discharge Professor
_______________________ as an individual; as well as North Carolina
Wesleyan College, Incorporated and its trustees, officers, employees, agents,
successors and assigns from any liability whatsoever; including, without
limitation to, liability for negligence or carelessness; and from any and all
claims for injuries (including death) or damages that arise out of, or relate in
any way to my travel to or participation in the following:
Activity:_________________________________________
Date:____________________________________________
Professor:________________________________________
Means of Transportation:____________________________
Executed this ___ day of ______________, 19__, under seal with the
intent that this shall be a "sealed instrument".
Student Signature _______________________________(SEAL)
Witness Signature _______________________________(SEAL)
Professor Signature ______________________________(SEAL)
In case of emergency, please contact the following:
Name:___________________________ Telephone:__________________
Relationship:____________________