Dear [Parents/Guardians],
_________________ (NAME OF SCHOLAR) has requested to participate in a travel program that is not
organized by or connected in any way with Partnership Scholars Program (PSP). The details of the trip
and the planned activities, as have been provided to us by the Scholar, are as follows:
[INSERT INFORMATION ABOUT PROGRAM OR ACTIVITY AND ANY DETAILS ABOUT TRAVEL].
PSP is not responsible for any activities which [NAME OF SCHOLAR] may participate in during the course
of the [ACTIVITY/PROGRAM/TRIP]. Moreover, [NAME OF SCHOLAR]’s PSP mentor will not accompany
him/her to the [ACTIVITY/PROGRAM/TRIP], nor will PSP arrange for any other chaperone to accompany
him/her for this [ACTIVITY/PROGRAM/TRIP]. You and [NAME OF SCHOLAR] are responsible for
__________________________________________ (transportation, etc.) to and from the
[ACTIVITY/PROGRAM/TRIP].
Nonetheless, (NAME OF SCHOLAR) has requested that PSP provide reimbursement for
____________________ (LIST EXPENSE TO BE REIMBURSED). PSP is willing to reimburse (NAME OF
SCHOLAR) for the expense because this trip and the activities are consistent with the mission of PSP.
However, before PSP will provide reimbursement (NAME OF SCHOLAR) and you are required to sign and
return the attached voluntary waiver. The purpose of the release is to ensure that PSP is not liable for
any harm that may result from or be related to (NAME OF SCHOLAR’S) trip. The waiver must be
received by PSP before the trip and before any funds will be released.
Please review the attached Agreement thoroughly before signing. If you have any questions, please do
not hesitate to ask.
Thank you,
Lisa Ruben
Executive Director
4290330.2 PA046-001
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PARTNERSHIP SCHOLARS PROGRAM
VOLUNATARY WAIVER, RELEASE AND INDEMNITY AGREEMENT (“Agreement”)
ACTIVITY/PROGRAM: _________________________________
SCHOLAR’S NAME: ___________________________________ (Print Full Name) (“Scholar”)
In consideration of Partnership Scholar’s Program (“PSP”) payment of Scholar’s ____________________
LIST TYPE OF EXPENSES PAID FOR BY PSP, e.g. program fees, flights, etc.] for ____________________
[NAME OF ACTIVITY/PROGRAM], the undersigned Scholar and parent/guardians of(s) of Scholar, on
behalf of his or her heirs, executors, administrators and assigns, and on behalf of Scholar acknowledge
and agree to the following:
1.
Acknowledgment and Assumption of Risk: I/We understand and acknowledge that certain risks
are inherent in ____________________ [NAME OF ACTIVITY/PROGRAM] (“Activity”) and assume
responsibility for any such risks associated with participation in the Activity. The risks include, but are
not limited to travel to [LIST TYPES OF RISKS INVOLVED IN ACTIVITY]:
_____________________________________________________________________________________
____________________________________________________________________________________.
Participation in the Activity may cause personal injury, including emotional trauma, injury and even
death. I/We understand that PSP has had no involvement in the planning of the Activity.
2.
Voluntary Release of All Claims: I/We understand that PSP is not an organizer or sponsor of this
trip or the activities associated with it. Moreover, PSP does not make any representations regarding the
safety or quality of the trip, nor has it encouraged Scholar’s participation in it. Nonetheless, to the
extent there may be claims Scholar or Parents/Guardians could bring against PSP, I/We voluntarily
release, discharge, waive and relinquish all claims against the PSP, its trustees, officers, agents and
employees, arising out of ordinary negligence that are in any way related to the Activity, including but
not limited to, claims for bodily injury, personal injury, emotional distress, property damage or wrongful
death. It is the intent of the parties that this release extends to any and all claims that may be brought
against PSP to the greatest extent permissible by law.
3.
Section 1542 Waiver. As a further consideration and inducement for this Agreement, to the
fullest extent permitted by law, I/We hereby waive and release any and all rights under Section 1542 of
the California Civil Code against PSP. Civil Code Section 1542 states, in its entirety:
“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW
OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH
IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH
THE DEBTOR.”
This Agreement shall extend and apply to all unknown, unsuspected, and unanticipated claims, injuries,
losses and damages as well as those that are now known or disclosed.
4.
Release from Third-Party Liability: I/We understand that PSP is not an agent of, and has no
responsibility for, any third party, __________________________ [NAME OF ORGANIZATION/BUSINESS
SPONSORING ACTIVITY], or any sponsor, vendor, or other entity that may provide any services,
hospitality, public and/or private transportation, equipment, training or activities associated with the
above mentioned Activity.
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[INCLUDE ONLY IF PSP IS ARRANGING FOR SCHOLAR’S TRAVEL]: In arranging for Scholar’s travel, PSP
uses commercial airlines whose performance and service cannot be controlled. Consequently, PSP is not
responsible for the actions of these commercial airlines for matters including, but not limited to, injuries
or damages caused by a third-party, strikes, lost luggage and the like.
5.
Indemnification/Hold Harmless: I/We understand and agree that I/We may be held liable and
responsible for any injury or death to another person or injury to property of another caused by Scholar.
I/We hereby agree to indemnify and hold harmless PSP, its trustees, officers, directors, representatives,
agents, employees and volunteers, with respect to any claims of injury, death or other loss or damage to
person or property suffered by any person arising in whole or in part from Scholar’s conduct while
traveling to and from and participating in the Activity.
6.
Medical Care: I/We understand that PSP will not accompany Scholar to the Activity and that
Scholar is responsible for seeking medical or dental care should he need to do so. I/We understand that
I must contact , __________________________ [NAME OF ORGANIZATION/BUSINESS SPONSORING
ACTIVITY], directly if I/We wish to provide an Activity staff member or other responsible adult with the
authority to consent to the administration of medical or dental care for Scholar, as deemed appropriate.
I/We understand that I/We shall be responsible for the full costs of the medical or dental care.
7.
Medical Insurance: I/We understand and acknowledge that PSP does not carry or maintain
health, medical, or disability insurance coverage for Jose. I/We therefore agree to assume full
responsibility for Scholar’s health insurance coverage.
8.
Pre-Existing Medical Conditions: I/We understand that neither Scholar’s mentor nor any other
PSP trustee, director, officer, representative, agent, employee or volunteer will accompany Scholar to
the Activity. I/We therefore understand that it is my/our responsibility to provide,
__________________________ [NAME OF ORGANIZATION/BUSINESS SPONSORING ACTIVITY]or any
other responsible adult with current information concerning any medical or physical conditions,
including, but not limited to, allergies, asthma or medications concerning Jose, and names and phone
numbers of emergency contacts. I/We release PSP, its officers, directors, representatives, agents,
volunteers, and employees, from all claims and liabilities for any illness, injury, loss of property and/or
death resulting during or after the Activity from Scholar’s pre-existing medical (physical, emotional
and/or psychological) conditions.
9.
Severability: If any provision of this Agreement is held to be invalid or unenforceable, the
remainder of this Agreement shall nevertheless remain in full force and effect.
10.
Choice of Law: This Agreement shall be governed by the laws of the State of California.
11.
Entire Agreement: This Agreement constitutes a single, integrated contract expressing the
entire Agreement of the parties as specified below. There are no other agreements, written or oral,
express or implied, between the parties hereto, concerning the subject matter hereto, except the
agreements set forth hereto. This Agreement may be modified or superseded only in a written
agreement that specifically references this Agreement and is signed by all parties.
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IMPORTANT – READ ENTIRE AGREEMENT BEFORE SIGNING
I/We have taken steps to become informed about the Activity and certify that I/we understand that
the trip and Orientation is a voluntary activity for _____________________ (Full Name of Scholar),
which is not sponsored by PSP. I have read this Waiver, Release, and Indemnity Agreement. By
signing this Agreement for the Activity, I/We acknowledge and agree to uphold all of the above
commitments and allow our child to participate in the Activity and to adhere and follow any
applicable transportation arrangement and rules.
I/we understand that signing this agreement is voluntary and that I/we have been given the
opportunity to seek legal counsel and to question PSP before signing this binding document.
Print Full Name of Parent/Guardian #1:
_______________________________________________
Parent/Guardian Signature _______________________________
Print Full Name of Parent/Guardian #2:
_______________________________________________
Parent/Guardian Signature _________________________________
Print Full Name of Scholar:
Date __________________
_______________________________________________
Scholar Signature _________________________________
4290330.2 PA046-001
Date ____________________
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Date __________________