University of Nevada - College of Engineering
Engineering Summer Camps 2016
Emergency Information and Waiver of Liability Form
(Must be completed and returned prior to event in order to participate)
Participant’s Name:
Camp Name:
Camp Dates:
Emergency Contact and Medical Information
1st Contact Person:
Best Daytime Phone#:
Relationship to Participant:
2nd Contact Person:
Best Daytime Phone#:
Relationship to Participant:
Participant’s Physician:
Phone#:
Participant’s Dentist:
Phone#:
Medical Information (allergies, recent illness, etc.):
Additional Information camp leaders may need:
Please list any medications the Participant is currently taking:
(Please register any medication with the camp director)
Please indicate which of the following first aid medications the Participant may take:
⎕ Advil ⎕ Tylenol ⎕ Aspirin ⎕ Pepto Bismol ⎕ Benadryl ⎕ Other: ________________
I, the undersigned Parent or Guardian, certify that the Participant has no ailment or organic defect that would make participation
in the camp dangerous to the health of the Participant. I hereby authorize the camp staff to act on my behalf according to their
best judgment in any emergency requiring medical attention, and as provided below waive and release the Board of Regents of
the Nevada System of Higher Education on behalf of the University of Nevada, Reno (“University”) and its employees, agents,
and representatives from any and all liability for injuries incurred while at camp.
Assumption of the Risk
I acknowledge that I have received a copy of the registration rules for this camp and that I have read and understand these rules.
I recognize and agree that participation in the camp is entirely optional and voluntary. I further understand and agree that such
participation may include the use of facilities, tools, equipment, and materials that are inherently hazardous and dangerous. I
ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, DAMAGE, OR INJURY TO PROPERTY OR PERSON,
INCLUDING DEATH, THAT MAY BE SUSTAINED AS A RESULT OF PARTICIPANT’S PARTICIPATION IN THE
CAMP, WHETHER CAUSED BY THE NEGLIGENCE OF THE UNIVERSITY OR OTHERWISE.
Indemnification
I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby agree to indemnify, defend,
and hold harmless the University and its employees, agents, and representatives, from and against any and all liability whatsoever
for any and all damages, losses, sicknesses, or injuries (including death) to person or property or both sustained by myself or
Participant, including but not limited to any claims, demands, actions, causes of action, judgments, expenses and costs, including
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attorney’s fees, which directly or indirectly arise out of, result from, occur during, or are connected or related in any manner with
Participant’s participation in the camp, whether caused by the negligence of the indemnified parties or otherwise.
Release of Liability
To the fullest extent authorized by law, I, individually, and on behalf of my heirs, successors, assigns and personal representatives,
hereby forever waive, release, discharge, and covenant not to sue the University and its employees, agents, and representatives,
from any and all liability, loss, damage, or expense, including attorney’s fees, that they or any of them incur or sustain as a result
of any claims, demands, actions, causes of action, damages, judgments, costs or expenses, including attorney’s fees, which directly
or indirectly arise out of, result from, occur during, or are in any way connected with or related to Participant’s participation in
the camp, whether caused by the negligence of the released parties or otherwise.
Transportation
I understand and agree that Participant will be transported and chaperoned by the University staff in either campus, public, or
private vehicle that meets with institution guidelines for insurance, licensing and seatbelt requirements or by emergency transport
if required.
Publicity
I grant the University permission to publish Participant’s name, photograph, video footage, and or story and publicize and
otherwise use his or her artwork for exhibition, education, and public awareness purposes. I hereby waive any privacy rights
afforded under applicable law with respect to the foregoing.
Acknowledgment
By signing below I hereby represent, acknowledge and agree as follows: I have read this entire document, understand it and sign
it voluntarily with knowledge that I am giving up substantial legal rights I might otherwise have; I am sufficiently informed of
the risks involving in participating in the camp to decide whether to sign this document; no oral representations, statements, or
inducements, apart from the foregoing written agreement, have been made to me; this document shall be governed by and
construed in accordance with the laws of the State of Nevada, including without limitation the provisions of Nevada Revised
Statutes Chapter 41; and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal
force and effect.
Parent/Guardian Name and Signature:
____________________________________
Print name
________________________________________
Signature
Date: ______________
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