Viterbo University
STUDENT PARTICIPANT ASSUMPTION OF RISK AND RELEASE OF LIABILITY FORM  
Please read the entire document before submitting.
 
I understand that the information requested is necessary for my participation in Viterbo University’s off-campus programs and/or activities.  I consent to the release of this information to Viterbo University for matters arising out of my off-campus program and/or activity participation.
 
I acknowledge that I am a student at Viterbo University.   I would like to participate in off-campus programs and/or activities associated with graduate requirements and optional, non-required activities at the university.
 
In consideration for being allowed to participate in off-campus programs and/or activities, I the undersigned, acknowledge, appreciate and agree that:
 
      1.  There are inherent risks involved with off-campus programs and/or activities, including but not limited to those associated with travel, transportation, injury, illness, and damage or loss of personal property, etc. and I choose to voluntarily participate in off-campus programs and/or activities with full knowledge that off-campus programs and/or activities may be hazardous to me and my property.
 
      2. I voluntarily assume full responsibility for any risk of loss, property damage or personal injury, including death, which may be sustained by me as a result of my participation in off-campus programs and/or activities.
 
      3. I further understand that the University provides no medical coverage for off-campus programs and/or activities. Should I incur medical expense, I understand that I am solely responsible for such costs.
 
      4. I certify that I have adequate health insurance necessary to provide for and pay any medical costs that may directly or indirectly result from my participation in off-campus programs and/or activities.
 
      5. I understand that off-campus programs and/or activities are/may be physically strenuous and I know of no medical reason why I should not participate.
 
      6. I hereby release, waive, and discharge Viterbo University and its Board of Trustees, its officers, agents, employees and representatives from all claims, demands, liabilities, rights and causes of action of whatever kind or nature, that may result from or occur during my participation in off-campus programs and/or activities.  I also agree to indemnify and hold harmless the University for any loss, liability, damage or costs, including court costs and attorney’s fees that may occur as a result of my negligent or intentional act or omission while participating in off-campus programs and/or activities.
 
TYPE YOUR NAME, DATE AND VITERBO ID NUMBER TO INDICATE YOUR AGREEMENT WITH THIS STATEMENT: I have carefully read this release of liability and assumption of risk and have had sufficient time to seek explanation of the provisions contained above. After careful consideration, I sign this document voluntarily and without any inducement.
 
    Viterbo ID
(The Viterbo ID Number begins with 99 as listed on your ID Card. Input 99 plus the rest of the ID number.)
  Participant Name        Email 
 
If participant is under the age of 18, his/her parent or legal guardian must also sign below: I am the parent or legal guardian of the participant who has signed above. I have read and I understand the provisions of this document, I consent to the participant taking part in the activity/program described above, and I fully enter into and agree to the above assumption of risk and release from liability.
Parent or Legal Guardian Name