PREVIEW
DAY
NSU
MULTIMEDIA
CAMP
Release and Waiver of Liability, Assumption
of Risk and Indemnity Agreement
Photo Release Form
Wednesday,
March 27, 2019
8:00 a.m.–6:00 p.m.
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NSU Multimedia Camp Peview Day
Release and Waiver of Liability,
Assumption of Risk and Indemnity Agreement
I,______________________________ (“Participant”), hereby acknowledge that I have voluntarily elected to
participate in the following activity/trip, NSU Multimedia Camp Preview Day (“Activity”), to be held in and
around Nova Southeastern University, on March 27, 2019. In consideration for being permitted by the Nova
Southeastern University (“NSU”) to participate in the Activity, I hereby acknowledge and agree to the following:
ELECTIVE PARTICIPATION: I acknowledge that my participation is elective and voluntary.
RULES AND REQUIREMENTS: I agree to conduct myself in accordance with NSU policies and procedures.
I further agree to abide by all the rules and requirements of the Activity. I acknowledge that NSU has the right to
terminate my participation in the Activity if it is determined that my conduct is detrimental to the best interests of the
group, my conduct violates any rule of the Activity, or for any other reason in NSU’s discretion.
INFORMED CONSENT: I have been informed of and I understand the various aspects of the Activity, including the
dangers, hazards, and risks inherent in the Activity, including but not limited to transportation to and from
Nova Southeastern University via private vehicle, common carrier and/or NSU owned vehicle, participation in
NSU Multimedia Camp, overnight accommodations, weather conditions, conditions of equipment, facility conditions,
negligent first aid operations or procedures, and in any independent research or activities I undertake as an adjunct to
the Activity. I understand that as a Participant in the Activity I could sustain serious personal injuries, illness, property
damage, or even death as a consequence of not only the NSU’s actions or inactions, but also the actions, inactions,
negligence or fault of others. I further understand and agree that any injury, illness, property damage, disability,
or death that I may sustain by any means is my sole responsibility except for those occurrences due to the NSU’s
negligence or intentional acts.
RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors,
administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE NSU,
its governing board, directors, officers, employees, agents, volunteers and any students (hereinafter referred to as
“Releases”) for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits,
or judgments of any and every kind (including attorneys’ fees), arising from any injury, property damage or death that
I may suffer as a result of my participation in the Activity, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR
DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE
RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR
DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY
ADJUNCT TO THE ACTIVITY, OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any
way responsible for any injury or damage that I sustain as a result of my own negligent acts.
ASSUMPTION OF RISK: I understanding that there are potential dangers incidental to my participation in the
Activity, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage,
or even death. I understand that there are potential risks as a consequence of, but not limited to: participation in
(SPECIFY activity), travel to and from (SPECIFIY) via private vehicles, common carriers, and/or NSU owned vehicles,
weather conditions, overnight accommodations, facility conditions, equipment conditions, first aid operations or
procedures of Releasees, and other risk that are unknown at this time.
I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING
FROM THE ACTS IF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEES’ INTENTIONAL OR NEGLIGENT
ACTS, and assume full responsibility for my participation in the Program.
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INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and
assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any
and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including
attorneys’ fees), arising from any injury, property damage or death that I may suffer as a result of my participation
in the Activity, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR
OTHERWISE, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR
INTENTIONAL ACTS.
PERSONAL MEDICAL INSURANCE: I agree to purchase and maintain during the term of the Activity personal
medical insurance. I further acknowledge that I am responsible for the cost of any and all medical and health services I
may require as a result of participating in the Activity. Current Medical Insurance Provider: ______________________
Medical Insurance Provider Membership # _______________________________________________________________
CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I am physically and mentally t to participate in
the Activity and that I do not have any medical record of history that could be aggravated by my participation in this
particular Activity.
MEDICAL CONSENT: I understand and agree that Releasees may not have medical personnel available at the
location of the Activity. In the event of any medical emergency, I (initial one) do _____ do not _____ authorize and
consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care
that NSU personnel deem necessary for my safety and protection. I understand and agree that Releasees assume no
responsibility for any injury or damage which might arise out of or in connection with such authorized emergency
medical treatment.
CHOICE OF LAW: I hereby agree that this Agreement shall be construed in accordance with the laws of the
State of Florida.
SEVERABILITY: If any term or provision of this Agreement shall be held illegal, unenforceable, or in conict with any
law governing this Agreement the validity of the remaining portions shall not be affected thereby.
I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT
INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY
THE RELEASEES. I UNDERSTAND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND
SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT I AM AT
LEAST EIGHTEEN YEARS OF AGE OR, IF NOT, THAT I HAVE SECURED BELOW THE SIGNATURE OF MY PARENT OR
GUARDIAN AS WELL AS MY OWN.
(See reverse side if participant is under eighteen (18) years of age)
I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS
AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND
WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with
Participant in granting a release to Releasees as set forth in detail above.
________________________________
Signature of Participant
________________________________
Signature of Parent or Guardian
___________________
Date
___________________
Date
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NSU Multimedia Camp Peview Day
Photo Release
I hereby give the unqualied right to Nova Southeastern University to take pictures and/or
recordings of me and to put the nished pictures/recordings to any legitimate
use without limitation or reservation.
Signature: ___________________________________________________________________________________________
Name Printed*: _______________________________________________________________________________________
Address: ____________________________________________________________________________________________
City: ________________________________________ State: _______________________ Zip: _______________________
Date: _______________________________________________________________________________________________
*If subject is a minor under laws of state where modeling is performed:
Guardian Signature: __________________________________________________________________________________
Guardian Name: _____________________________________________________________________________________
City: ________________________________________ State: _______________________ Zip: _______________________
Date: _______________________________________________________________________________________________