Loading...

UAA Summer Engineering Academies - 2022
 

AGREEMENT TO RELEASE ALL CLAIMS FOR INJURY AND TO PROTECT

THE UNIVERSITY AND OTHERS FROM ANY SUCH CLAIMS THAT MAY BE BROUGHT

(FOR MINOR PARTICIPANTS - AGE 17 AND YOUNGER)

 

My child, identified above, has chosen to be a participant in the above referenced Event. As his/her parent/legal guardian, I support my child’s decision to participate in this Event and, by signing below, indicate that I have reviewed the following information with my child and that we understand and agree to the information presented.

 

I have made this choice in recognition and appreciation that there will be known and unknown risks, dangers and hazards which may be encountered in the above-mentioned Event.  These risks, dangers and hazards include, among others, defective equipment which may break, be improperly adjusted, or be ill suited to my child’s abilities or physical size or condition; and inadequate or erroneous information about risks, faulty warnings or improper directions from the University personnel. I understand that these risks can cause permanent physical and mental injury or death (herein collectively referred to as “injury”). I also recognize that these consequences may be caused by the negligence or gross negligence (herein collectively referred to as “fault”) of the University of Alaska or fellow participants. 

 

With all of the above risks, dangers, hazards and consequences in mind, I DO HEREBY VOLUNTARILY ASSUME ALL RISKS, DANGERS AND HAZARDS that I or my child may encounter during participation in, and transportation to, from or as a part of, the Event. In addition, I declare that I intend that I, not the University, will be financially responsible for any injury that may occur to me or my child during or as a result of such participation or transportation, even if caused by the fault of the University.

 

Further, in consideration of being permitted to participate, I hereby agree to release the University of Alaska, its board of regents, officers, agents, and employees, (Released Parties) from all liability and claims of any kind, including claims for loss, expense, damages, punitive damages or attorney fees, or loss of companionship or support of family, occurring during or as a result of participation in, or transportation to, from or as a part of this Event (Claims). This release applies even if such Claims are based on the fault of Released Parties.

 

Further, I promise to indemnify and hold harmless the University of Alaska, and pay its costs of defense, if Claims are brought by me, my child, or anyone else against any of the Released Parties to recover money damages related to injury to or death of me or my child. This promise applies even if the Claims are based on the negligence or gross negligence of the University or other related parties

 

I understand that special personal accident insurance may be available to me, upon my request at my expense, through University of Alaska managed plans or otherwise, and that any obligation to purchase insurance is entirely mine.

 

I have entered into this agreement on the basis of my own information and not in reliance upon representations of the University or other Released Parties. I understand that I have the right to consult an attorney of my choice before signing. I further understand that this document contains the entire agreement and no oral or written agreements limiting or modifying the effect of the terms of this agreement exist. I agree that if any part of this agreement is held to be invalid or unenforceable for any reasons, the balance of the agreement remains valid and enforceable.

 

I intend that this agreement is and will be binding on my family, estate, heirs, successors, assigns, insurers, medical providers and personal representatives.

 

By my signature, I represent that I have knowingly and voluntarily signed this agreement with the intent that it be a legally binding document designed to protect the University of Alaska and other Released Parties from all Claims which could be brought by myself or anyone else on account of injury to me or my child, regardless of cause or fault.

 

In consideration of UA’s allowing the child to participate in the Event, the undersigned parent(s) or guardian agree on their own behalf, and on behalf of their child, to release UA from any claim the child, parent(s) or guardian may have because of injury or loss suffered by the child, including injury or loss claimed to be caused by the fault of UA. In addition, the parent(s) or guardian agree on their own behalf to protect and indemnify UA from any claim and related expenses and fees, brought at any time by the child or by anyone on the child’s behalf, or by any member of the child’s family, arising out of the child’s enrollment or participation in the activity.

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Other Info
What is the participant's ID number (PID)? This number can be found on your admission results email. *
PHOTO/MODEL RELEASE The University of Alaska Anchorage (UAA) and or parties designated by UAA to copy, reproduce or publish the participant's photograph, or likeness, for the purpose of illustration, advertising, display, audiovisual and public relations purposes*
No
Yes
Does this participant have permission to leave UAA's campus without an authorized adult, i.e., they may walk, bike, or bus home after camp?*
No
Yes

List the first and last names of all authorized adults who may pick up this participant. *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!