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Name%and%Relationship% ECPI%University% LLC%(the%University)% strongly%recommends% health% insurance%for% our%students.% Please%read,% (ECPI University)

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ECPI%University% LLC%(the%“University”)% strongly%recommends% health% insurance%for% our%students.% Please%read,% initial,%
and%sign%below:%
%I%have%h e a lth %in s u ra n ce %c o ve ra g e. %(A %copy%of%ins u ra n c e%in f o rmation%p ro v id e d )%
%I%do%no t %w is h %to %p urchase%h e a lth %in s u ra n c e.%
_________________________________% will%be%paying%for%my%medical%expenses%while%I%am%in%the%U.S.%
Name%and%Relationship%
I%hereby%acknowledg e %that%the%University%has%recommended%that%I%purchase%health%insurance%and%informed%me%of%
some% of%the%potential%risks%of% not% pu rchasing% health% insurance.% I% unde rs ta n d % the% imp o rta n ce % of% havin g % hea lth %
insuranc e .% If% I% have % decided % not% to% purchase% health% insuran c e,% I% a m % fully% responsib le % for% any% and% all% med ic a l%
expenses%I%may%incur.%
%I,%on%behalf%of%myself,%my%estate%and%my%heirs,%hereby%expressly%waive%and%release%any%and%all%claims,%now%known%
or% hereafter% known,% against% the% University% and% its% officers,% directors,% employees,% members,% agents,% affiliates,%
successors,%and%assigns,%and%any%external%program%and/or%training%site%at%which%I%may%participate%(collectively,%the%
"Released%Parties"),%arising%out%of%or%related%to%(1)%my%failure%to%purchase%or%maintain%health%insurance%and/or%(2)%
my%participation%in%any%external%program%and/or%training% site%at%w hich% I%m ay% participate.%%I% c o ve n a n t%not%to%make%
or%bring% any% such%claim%against%the %Relea sed %Parties%and%forever%release% an d%discharge% th em %from %liab ility%unde r%
such%claims.%
I,%on%behalf%of%myself,%my%estate%and%my%heirs,%shall%defend,%hold%harmless%and%indemnify%the%Released%Parties%
against% any% and% all% loss e s,% dam a g es ,% liabilitie s,% deficie n cie s ,% claims ,% action s ,% judgments,% settlements,% interest ,%
awards,%penalties,% fines,%costs,%or%expenses% o f%w hatever%kind,%including%attorneys’%fees,%that%are%incu rred %by%the%
Released%Parties%arising%out%of%or%related%to%(1)%m y% failure%to%purchase%or%procure%health%insurance%and/or% (2)%my%
participation%in%any%external%program%and/or%training%site%at%w hich%I%may%participate.%%Any%such%external%program%
and/or% trainin g% site% is% an% inte nd ed % third-party%beneficiary%of%my% liability% release%and% the % ind emnity% and % o th e r%
obligations%set%forth%abo ve.%%This%agreement% is%b inding%o n% and% shall%inure% to% the%benefit%of% the% University%and% me%
and%our% respe ctive%heirs,%executors,%administrators,%su ccessors%and% a ssigns.%%If%any%pro vis io n %of%this%agreement% is%
invalid,%su ch %in va lid ity %shall%not%affect%any%other%provision.%%%
BY#SIGNING,#I#ACKNOWLEDGE#THAT#I#HAVE#READ#AND#UNDERSTOOD#ALL#OF#THE#TERMS#OF#THIS#AGREEMENT#
AND#THAT#I#AM#VOLUNTARILY#GIVING#UP#SUBSTANTIAL#LEGAL#RIGHTS,#INCLUDING#THE#RIGHT#TO#SUE#ECPI#
UNIVERSITY#LLC#AND#OTHER#PARTIES.##
________________________________________________________% % ___________________%
Print%Student%Name%% % % % % % % % Date%
________________________________________________________%
Signature%
I%am%the %p a re n t%o r %leg a l%g u ar d ia n %o f%th e %minor%na med%abo v e. %%I%hav e%t h e %leg a l%rig h t%t o %co n s e n t%to %a n d ,%b y %sig n in g %
below,%I%hereby%do%consent%to%the%terms%and%conditions%of%this%agreement.%
________________________________________________________% ___________________%
Print%Parent/Legal%Guardian%Name%% Date%
________________________________________________________%
Signature%
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Name%and%Relationship% ECPI%University% LLC%(the%University)% strongly%recommends% health% insurance%for% our%students.% Please%read,% (ECPI University)

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Completed 15 August 2020

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