Program Name
CAMP & ENRICHMENT PROGRAM
WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM
1. EXCULPATORY CLAUSE. In consideration for receiving permission for my/my child’s
participation in any and all activities of ______________________________ (herein referred to
as “camp”), which is sponsored by ______________________________, (herein referred to as
“sponsor”), I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless
for any and all purposes sponsor, The Texas A&M University System, the Board of Regents for
The Texas A&M University System, Texas A&M University, and their members, officers, servants,
agents, volunteers, or employees (herein referred to as RELEASEES or INDEMNITEES) from
any and all liabilities, claims, demands, injuries (including death), or damages, including court
costs and attorney’s fees and expenses, that may be sustained by me/my child while participating
in such activity, while traveling to and from the activity, or while on the premises owned or leased
by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent
negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I
understand this waiver does not apply to injuries caused by intentional or grossly negligent
conduct.
2. INDEMNITY CLAUSE. I am fully aware that there are inherent risks to my child,
myself and others involved with this activity, including but not limited to
____________________________________________________, and I choose to voluntarily
participate/allow my child to in said activity with full knowledge that the activity may be hazardous
to me, my child and my property, and to the person and property of others. I acknowledge there
may be physically strenuous activities. I know of no medical reason why I/my child should not
participate. I agree to indemnify and hold harmless INDEMNITEES
from any and all liabilities,
claims, demands, injuries (including death), or damages, including court costs and attorney’s fees
and expenses, which may occur to myself, my child, other participants, and third-persons as a
result of my/my child’s participation in said activity, including injuries sustained as a result of
the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict
liability of INDEMNITEES.
3. NO INSURANCE. I understand that RELEASEES may or may not maintain any
insurance policy covering any circumstance arising from my/my child’s participation in this activity
or any event related to that participation. As such, I am aware that I should review my personal
insurance coverage. Organization may not carry general liability insurance to cover claims
arising from this activity so it seeks a waiver of claims as additional consideration for the right to
participate so organization, can (a) provide the activity at the lowest possible cost to participants;
and (b) provide access to a greater number of participants by expending limited resources on
program materials rather than on liability insurance.
4. BINDS HEIRS. It is my express intent that this agreement shall bind the members of
my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am
deceased, and shall be governed by the laws of the State of Texas.
5. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and
WAIVER. I understand RELEASEES cannot be expected to control all of the risks articulated in
this form and RELEASEES may need to respond to accidents and potential emergency
situations. Therefore, I hereby give my consent for any medical treatment that may be required,
as determined by a medical professional at the medical facility, during my/my child’s participation
in this activity with the understanding that the cost of any such treatment will be my responsibility.
Print Form
TAMUS-OGC-Approved 06/2007
I agree to indemnify and hold harmless INDEMNITEES for any costs incurred to treat me/my
child, even if an INDEMNITEE has signed hospital documentation promising to pay for the
treatment due to my inability to sign the documentation. I further agree to release, waive,
discharge, covenant not to sue, and agree to hold harmless for any and all purposes,
RELEASEES from any and all liabilities, claims, demands, injuries (including death), or damages,
including court costs and attorney’s fees and expenses, that may be sustained by me/my child
while receiving medical care or in deciding to seek medical care, including while traveling to and
from a medical care facility, including injuries sustained as a result of the sole, joint, or
concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES.
I understand this waiver does not apply to injuries caused by intentional or grossly negligent
conduct.
6. VOLUNTARY SIGNATURE. In signing this agreement I acknowledge and represent
that I have read it, understand it, and sign it voluntarily as my own free act and deed; sponsor has
not made and I have not relied on any oral representations, statements, or inducements apart
from the terms contained in this agreement. I execute this document for full, adequate and
complete consideration fully intending to be bound by the same, now and in the future. I
understand I can choose not to sign this document and free myself and my child from its terms
and the associated risks of the activity by simply not participating in the activity and choosing
some other activity available to me/my child that has a lower level of risk to myself and my child. I
further understand this is a voluntary, extracurricular activity. While I understand alternative
activities are available to me/my child that do not have the risks associated with this activity I still
desire to voluntarily engage/permit my child to engage in this activity.
SIGNING THIS DOCUMENT INVOLVES THE WAIVER OF VALUABLE LEGAL RIGHTS.
CONSULT YOUR ATTORNEY BEFORE SIGNING THIS DOCUMENT.
SIGNED this _______ day of ____________________________, 20________.
Participant Signature:
Printed Name:
Participant’s Date of Birth:
Parent or Legal Guardian Signature:
(If Participant is under 18 years old)
Parent or Legal Guardian Printed Name:
(If Participant is under 18 years old)
If the participant has medical insurance, please indicate:
Insurance Company:
Policy Number:
Name of Primary Policy Holder:
Please list any special services your child may require:
In case of emergency, contact
at the following number
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