ACKNOWLEDGMENT AND WAIVER OF LIABILITY
Name:_______________________________________________
Boston University Identification Number: U _ _ - _ _ - _ _ _ _
Person to call in emergency:
Name:_______________________________________________
Home Phone: ________________________________
Work Phone: ________________________________
I would like to participate in Alternative Spring Breaks (ASB), which is an optional,
elective, extra-curricular activity offered by the Boston University Community Service Center.
I acknowledge that I am aware that there are risks to me of injury or property damage
entailed in my participation in this extra-curricular activity, including the risks of travel to and
from these activities. I do fully and completely assume any risks solely to myself, and accept
full responsibility for my individual physical fitness to participate in these activities. Although
Boston University will provide as much information as possible on each activity, I also
acknowledge that it is my responsibility to request further information about a specific extracurricular activity if I require such information in order to make a proper participation decision.
I understand that the University gives no assurances or guarantees whatsoever as to the safety of
participants in these programs.
I understand that this release and indemnification applies to all elective activities offered
through the Boston University Community Service Center in which I choose to participate. I
also understand that I am not required to participate in any elective activity. My participation in
any elective activity is a voluntary decision on my part.
In consideration of being presented opportunities to participate in extra-curricular
activities and in acknowledging that I am aware of and willing to assume the risks associated
with these activities, I hereby voluntarily agree to waive, hold harmless and indemnify the
Trustees of Boston University and its trustees, agents, volunteers and employees from any and all
claims, demands, damages and causes of action of any nature whatsoever arising out of ordinary
negligence which I, my heirs, my assigns or successors may have against them for, on account
of, or by reason of my voluntary involvement with elective activities offered by the Boston
University Community Service Center. I understand the content of this document, and I execute
this GENERAL RELEASE, WAIVER OF CLAIM AND ASSUMPTION OF RISK
AGREEMENT of my own free will and accord during my tenure at Boston University.
SIGNATURE:___________________________________________
DATE:_______________
PARENT OR GUARDIAN SIGNATURE:_____________________________________
(If under 18 years of age)
DATE:_______________