RISK AND RELEASE FORM
PRINT CLEARLY & LEGIBLY:
Name of Club: ________________________________________________________________________
Name of Activity: ______________________________________________________________________
Date(s): __________________________________________Time: _______________________________
• I understand that my participation in this activity is voluntary and I am physically t to participate.
• I agree fully understand the written safety and other rules and precautions that are part of the
requirements for my participation in the above referenced activity as well as those explained to me
by my advisor(s).
• I do for myself, my heirs, executors, and administrators accept full responsibility for the indemnity,
release, and discharge the University of Hawaii, its ofcers, agents, and employees from any and
all claims of actions for property damage and/or personal injury in which may result from my failure
to abide by these safety rules and precautions or from any inherent risk in said activity.
EMERGENCY CONTACT INFORMATION
NAME (PRINT): ________________________________________________________________________
PHYSICIAN’S NAME: _________________________ PHONE NUMBER: _______________________
MEDICAL INSURANCE (CHECK ONE OF THE FOLLOWING):
O My medical insurance carrier is: __________________________________________________
O I DO NOT HAVE medical insurance
IN CASE OF AN EMERGENCY PLEASE CONTACT THE FOLLOWING PERSON:
Name (Print):__________________________________ Relation: ___________________________
Home Phone Number: ______________________ Work Phone Number: _______________
O Yes, we (I), __________________________, do consent to authorize any medical doctor, dentist or
others working under their supervision to treat ______________ for any injury or illness.
O No, we (I), __________________________, do not consent to or authorize any medical doctor,
dentist, or others working under their supervision to treat____________________ for any injury or
illness. Therefore, we (I) agree to assume the risk of any injury or damage from the lack of any
medical treatment and further agree to release, discharge and hold harmless the State of Hawaii,
its employees and agents from and against any liability and any claim or demand arising out of or
in connection with said failure to provide any medical care or treatment.
Name (Print): ___________________________________ Student ID #: _________________________
Signature: ________________________________________________ Date: ___________________
PARTICIPANT UNDER THE AGE OF 18 REQUIRES PARENT OR GUARDIAN’S SIGNATURE
Parent/Guardian Signature: ______________________________________ Date: __________________
Home Address: _________________________________ Phone Number: ________________________