Persons on Non-Employee Working Status
University of Guelph
Forms
BY SUBMITTING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO
SUE - PLEASE READ CAREFULLY!
Version 2.0 (September 2008) Page 2 of 2
To submit this form:
Click the Print button to print the form. Obtain all required signatures Fax the completed form to
(519) 836-3278 or Mail to Insurance Office, University Centre L5, University of Guelph.
Name:
Telephone:
Address:
RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY:
In consideration of approval to enter a work experience program in the University of Guelph's
, from to
,
I hereby agree as follows:
▪ TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the University of Guelph and its
directors, officers, employees, and representatives ( all of who are herinafter collectively referred to as "The Releasees");
▪ TO RELEASE THE REALEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or
that my next of kin may suffer as a result of my participation in this work experience program, due to any cause
whatsoever, including negligence, breach of contract or breach of any statutory or other duty of care.
▪ IT IS MY RESPONSIBILITY to ensure I have adequate medical, personal health, dental and accident insurance
coverage, as well as protection of my personal possessions;
▪ TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability fo rany damage to property of, or
personal injury to, any third party, resulting from my participation in this work experience program, if such liability is as
a result of my acting outside the scope of my duties and responsibilities.
▪ THIS AGREEMENT SHALL be effective and binding upon my heirs, next of kin, executors, administrators, assigns and
representatives in the event of my death or incapacity;
IN ENTEREING INTO THIS AGREEMENT, I am not relying upon any oral or writeen representation or statements made
by the Releasees other than what is set fort in this Agreement
▪ I FREELY ACCEPT AND FULLY ASSUME all risk, dangers and hazards and the possibility of personal injury, death,
property damage or loss, resulting from my particpation in this program.
I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY COMPLETING AND
SUMBITTING THIS AGREEMENT I AM WAVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN,
EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES.
Date: Person's Signature
Relationship to Minor
Chair or Director Signature (Witness)
Send Copies to: Environmental Health and Safety 9
Risk and Insurance Manager
Signature of Parent or Legal Guardian
(if Person is a Minor)
