Brandeis University
Assumption of Risk and Release Agreement
I _______________________, by my signature below, hereby knowingly,
willingly and voluntarily consent to participate in the research and evaluation project
_______________________ sponsored by _______________________ from
________________, 20 _ through _______________, 20_.
I acknowledge that participation in ___________________is optional, and I
hereby knowingly and voluntarily consent to travel to___________________ for this
project. I understand that there are inherent risks involved with travel to
________________ and beyond the control of Brandeis University, and that Brandeis
cannot guarantee my safety or security.
I further acknowledge that I have been informed there is a U.S. Department of
State Travel Warning against travel by United States citizens to _________________ and
that in spite of such warning I have knowingly and willingly made the decision to travel
to _________________. I acknowledge that I am advised to monitor the United
States Department of State website (http://travel.state.gov) for updates and
additional information.
I hereby acknowledge and understand that Brandeis University neither accepts nor
assumes responsibility for my welfare, or for any injuries, claims or losses arising from
my participation in the trip. In consideration for my participation in the trip, I, on behalf
of myself, my executors, heirs, administrators or assigns, hereby release and forever
discharge Brandeis University, its Trustees, officers, employees, agents of and from any
claims or causes of action arising from my participation in the trip. In addition, I hereby
agree to release, indemnify and forever discharge Brandeis University of and from
contribution or indemnification with respect to any claim made against me by any person
or entity in connection therewith, or against Brandeis in connection with my acts or
omissions during the trip.
I hereby acknowledge that I have read and understood the above statements, and I
represent that I am of the specified legal age in my State of residence to bind myself to
this Release. This Release has been executed on behalf of myself, my heirs and assigns.
This instrument has been executed in and shall be governed by the laws of the
Commonwealth of Massachusetts.
Signature_________________________________ Date_________________________
Name Printed_____________________________