WAIVER OF LIABILITY AGREEMENT 

I, the undersigned participant, request voluntary participation for myself to participate in the ______________________________________________________________________________________ ______________________________________________________________________________________ ____________________________________________all of which are hereinafter referred to as the “activity”.

I consent to participation in the activity and acknowledge that I fully understand my participation may involve risk of serious injury or death, including losses which may result not only from my own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, and/or the rules of play of this type of event or activity. I understand that if I have any risk concerns, I should discuss the risks associated with my participation with the activity coordinators and event staff, before I sign this document and before the activity begins.

I certify that I am in good health and have no physical condition that would prevent participation in this activity. Furthermore, I agree to use my personal medical insurance as a primary medical coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required.

Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume responsibility for all risks and dangers associated with my participation in the activity. I agree I am financially responsible for any losses resulting from my actions and will indemnify Curtin University and the officers, employees and agents of each of them, for any loss or damage caused by myself during this activity.

In consideration of my participation in the activity, I hereby waive all claims or causes of action against Curtin University, campus department, and the officers, directors, employees and agents of all of them, arising out of my participation in the activity and hereby release, hold harmless, and discharge Curtin University campus department, and the officers, directors, employees and agents of each of them from all liability in connection therewith except such loss or damage which was caused by the sole negligence or willful misconduct of Curtin University, campus department, and it’s officers, employees, representatives and volunteers, and the officers, directors, employees and agents of each of them.

I have read this waiver of liability agreement and understand the terms used in it and their legal significance. This waiver and release is freely and voluntarily given with the understanding that right to legal recourse against Curtin University, and the officers, directors, employees and agents of each of them is knowingly given up in return for allowing my participation in the activity. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

Please utilize the space below to provide any

medical/prescription information that you

request be released to emergency medical providers.

______________________ ________________ Emergency contact name (print) (Area code) Phone number

________________________________________ Relationship to the participant

List medical/prescription information below:

__________________________________________ __________________________________________ __________________________________________ _____________________________ ____________

Participant’s signature date

_______________________________ ___________ Participant’s Name (print) (Area code) Phone no.

___________________________________________ Address City/State Zip

WITNESS (must be at least 18 years old)

_______________________________ ___________ Witness’s Name (print) (Area code) Phone no.

________________________________ ________ Signature date

* If excursion is more than 1 day, please fill in the attached Travel Diary Form

Excursion Form 

School:________________________ Department: _________________________________ Field Trip description: __________________________ Location: ________________________

Begins on __________________ (date/time) and will return on ___________________(date/time) Accompanying University employee: ____________________Phone no. ____________________

Field Trip Participant List

TRAVEL DIARY