WINTHROP UNIVERSITY
ASSUMPTION OF RISK, RELEASE AND INDEMNIFICATION
I, _____________________________, and the undersigned, in full recognition and
(Print or Type Name)
appreciation of the hazards and exposures involved do hereby voluntarily agree to assume
all of the risks and responsibilities involving my voluntary participation in
_______________________________________________________________________
(Program or Event)
scheduled from ___________________________________________________, 2_____,
(Month(s)/Date(s)
or any dependent research or activities undertaken as an adjunct thereto; and, further, I do
for myself, my heirs, and personal representative(s) hereby defend, hold harmless,
indemnify and release and forever discharge Winthrop University and all its officers,
agents, employees and volunteers from and against any and all claims, demands, and
actions, or causes of actions of any sort on account of damage to personal property, or
personal injury, or death which may result from my participation.
I confirm that I have health and accident insurance in effect for the inclusive dates of my
participation and no such coverage is provided for me by Winthrop University.
I have read and executed this document with full knowledge of its significance. In
witness whereof, I have caused this release and indemnification agreement to be executed
this __________________ day of _____________________, 2_________.
(Today’s Date) (Month)
_____________________ _______________ ___________________ ______________
(Student/Intern/Volunteer (Date) (Witness Signature) (Date)
Signature)
______________________________________________________________________________________
If Student/Intern/Volunteer is under the age of eighteen (18):
_________________ ____________ ________________ ____________
(Parent or Guardian (Date) (Witness Signature) (Date)
Signature)
____________________ _______________
(Parent or Guardian (Date)
Signature)
If Student/Intern/Volunteer is married:
_________________ ____________ ________________ ____________
(Spouse) (Date) (Witness Signature) (Date)
