SORS 8/5/2005 Page 1 of 4
Rev 7/11/2006
Rev 8/15/2019: Updates to include Protection of Minors Requirements
Rev 7/31/2020: Inclusive of SRC, Patty Ice, Patty Pool
This Agreement, dated this ________day of ___________________, 20______, is between the University of Alaska, hereafter
referred to as “UA” and ____________________________________________________________________ hereafter referred
to as “Permittee”.
Permittee Contact Information:
Name: ______________________________________________________________________________________________
Address: ______________________________________________________________________________________________
Phone: ______________________________________________________________________________________________
1. FACILITY/PREMISES. UA agrees to permit location 1900/1910 Tanana Drive, Fairbanks, AK 99775 under the terms
and conditions described below.
Check the property(s) that applies to this agreement:
Student Recreation Center
Permittee is responsible for compliance with all SRC rules. Permittee shall provide all participants with a copy of
rules upon request. Rates and rules may be found at &/or as attached.
Patty Ice Arena
Permittee is responsible for compliance with all Patty Ice Arena rules. Permittee shall provide all participants with
a copy of rules upon request. Rates and rules may be found at &/or as attached.
Will you need a concessions agreement?
Yes No
Patty Pool
UA will furnish qualified and certified lifeguards in accordance with American Red Cross Lifeguard ratio
guidelines upon request of the Permittee; minimum ratio: (1) lifeguard per (25) participants. Additional fees may
apply and may be charged at any time. Scheduling requires advance notice and must be in email form to the Pool
Permittee is responsible for compliance with all Patty Pool rules. Permittee shall provide all participants with a
copy of rules upon request. Rates and rules may be found at
regulations.pdf &/or as attached.
SORS 8/5/2005 Page 2 of 4
Rev 7/11/2006
Rev 8/15/2019: Updates to include Protection of Minors Requirements
Rev 7/31/2020: Inclusive of SRC, Patty Ice, Patty Pool
Provide the required information for all of the following:
Number of participants: ________ Number of spectators (if applicable): ________
Ages of participants (check all that apply): 0-12* 13-17* 18-20 21+
Please estimate the number of attendees under 18 years of age: ________
Sign here to certify that all minors will be supervised by their parents/guardians
during the event:
Print Name: _______________________________________________________________________
Signature: _______________________________________________________________________
Date: ___________________________
2. TERM. The term of this Agreement is from ___________________________ to ________________________________.
3. PERMITTED USES. Permittee shall use the UA facility/premises only for the following activities:
4. SCHEDULE OF USE PERIODS. Scheduling shall be solely within the province of UA. Permittee shall, upon request,
submit written schedules of dates and times for its use of the facility/premises during periods covered by the request.
Permittee shall designate one individual as a scheduler who will coordinate all space allocations with the particular UA
Facility Supervisor. Upon approval of any schedule, UA will make a good faith effort to reserve the facility/premises for
the date and time requested. The parties acknowledge that there are numerous users of the facilities/premises whose time
and needs UA must attempt to coordinate. The Permittee shall follow the cancellation policy for the particular facility
utilized within this Agreement. UA does not guarantee availability of the facility/premises. UA shall not, in any event, be
liable for unavailability of the facility/premises.
5. INDEMNIFICATION. Permittee assumes all responsibility, risk and liability for all activities of permittee, its
employees, agents, invitees, contractors, subcontractors, or licensees, directly or indirectly conducted in connection with
this Agreement, including environmental and hazardous substance risks and liabilities, whether occurring during or after
the term of this Agreement. Permittee agrees to the fullest extent permitted by applicable law to indemnify and save
harmless the University, its Board of Regents, officers, agents and employees, from and against all claims, demands,
judgments, costs and expenses (including reasonable attorney's fees) which may arise by reason of injury, emotional
distress, or death to any person, or damage to any property, which may have arisen or be alleged to have arisen in
connection with negligence of the Permittee; or which may arise or be alleged to have arisen as a result of a dangerous
condition of or on the premises, unless the condition had not become more dangerous as a result of the Permittee’s
activities. Permittee shall accept any such cause or action or proceeding within 15 days of tender by the University of
Alaska. This indemnification shall survive the termination of the Agreement.
*If minors are not supervised by their guardians at all times, additional requirements will need to be met. Minors on UAF
campuses require compliance of ALL applicable sections of the Protection of Minors Policy. You are responsible to provide a
copy of the policy to all your participants’ parents, volunteers, staff, employees and chaperones. Copy of policy is here: . You must also sign a copy of the UAF certification form and provide insurance that covers claims
for abuse which can be found at
click to sign
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SORS 8/5/2005 Page 3 of 4
Rev 7/11/2006
Rev 8/15/2019: Updates to include Protection of Minors Requirements
Rev 7/31/2020: Inclusive of SRC, Patty Ice, Patty Pool
Permittee expressly waives any and all claims of whatever nature, for any and all loss or damage sustained from any cause
whatever, prior, during, or subsequent to the rental period, by reason of any defect, deficiency, failure, or impairment of
the premises, including, but not limited to the water supply system, heating system, wires leading to or inside the premises,
gas, electric, or telephone systems, automatic sprinkler systems or from any other source whatsoever. UA is not liable or
responsible for any financial loss incurred by the Permittee due to unforeseen, extenuating or uncontrollable events, which
cause failure of any or all of the facilities to operate or function during the period of this Agreement.
6. INSURANCE. Without limiting its indemnification, and at least two weeks prior to the intended use, Permittee will
furnish UA with a Certificate of Insurance evidencing insurance coverage as indicated below:
6.1 Check either (A) or (B) below:
(A) Permittee’s policy of commercial general liability insurance with a minimum limit of $1,000,000 per
The commercial general liability insurance must include coverage for liability assumed under an insured
contract (including defense costs assumed under contract) and shall name UA as an additional insured. This
insurance shall apply as primary insurance with respect to any other insurance or self-insurance programs
afforded to UA.
(B) Permittee shall purchase liability insurance from the UA for a price of $____________ (see rate schedule).
6.2 Workers Compensation insurance meeting the required statutory limits unless Permittee provides:
I) A certificate of waiver approved by the Alaska Department of Labor; or
II) Other sufficient written proof and/or affidavit that establishes to the satisfaction of UA that
Permittee does not have any employees covered by the Alaska Workers Compensation Act.
Permittee shall purchase at its own expense, and maintain in force at all times during the term of this Agreement, the
insurance required in this section. Failure to furnish satisfactory evidence of insurance, lapse of a policy, or inadequate
limits, is grounds for termination of this Agreement. All insurance limits are minimum. If the Permittee’s policies contain
higher limits, the UA shall be entitled to coverage to the extent of such higher limits.
See page 1 footnote 1 of this agreement for additional insurance requirements as they pertain to minors.
7. PERSONAL PROPERTY. Permittee, not UA, is responsible for loss of, or damage to, any personal property of
Permittee, its guests, agents, employees, or invitees located within or on UA property, before, during, or after the term of
the Agreement.
8. USE OF UA NAME OR LOGO. Permittee agrees not to use the name or logo owned by or associated with the UA or
the name of any representative of the UA in any form of publicity without the written permission of the UA in each
9. CLEANING-VANDALISM. During the periods of facility/premises use by Permittee, Permittee shall be responsible for
vandalism or damages occurring during its use. Permittee shall be responsible for the expense of cleanup at the conclusion
of each use.
10. ADDITIONAL SERVICES. Permittee shall reimburse UA for any and all services not included in this Agreement but
requested by Permittee or required to fulfill Permittee’s responsibilities under the terms of this Agreement including, but
not limited to, cleanup not accomplished by Permittee.
11. RENT. Permittee agrees to pay to UA the sum of $_________________________ for the use of the facility/premises.
Said sum will be paid at least seven (7) days before the intended use of the facility/premises, or if pre-approved by the
appropriate UA fiscal officer, multiple pre-scheduled payments for rental time periods of a month or more. Charges for
cleaning and damages will be billed to the address of the Permittee as shown below and are due in full upon receipt of the
12. ASSIGNMENT. No benefit under this Agreement may be assigned nor may any duty under this Agreement be delegated
without the written consent of the other party.
SORS 8/5/2005 Page 4 of 4
Rev 7/11/2006
Rev 8/15/2019: Updates to include Protection of Minors Requirements
Rev 7/31/2020: Inclusive of SRC, Patty Ice, Patty Pool
13. TERMINATION. This Agreement may be terminated by either party in the event of non-performance by the other.
14. INTERPRETATION. This Agreement constitutes the entire agreement between the parties, superseding all previous
representations, discussions, and agreements between the parties. This Agreement shall be binding upon and shall inure to
the benefit of the successors and, subject to the provisions relating to assignment, the assigns of each of the parties. This
Agreement shall be interpreted in accordance with Alaska law, excepting choice of law provisions. Suit or claims related
to this agreement must be brought in the superior court for the 4th Judicial District, at Fairbanks, Alaska.
15. NOTICES. Any notices concerning this Agreement and all notices required by this Agreement shall be given in writing
and shall be personally delivered or mailed to the addresses designated by the parties below.
______________________________________________ ___________________________________________________
______________________________________________ ___________________________________________________
BY: ___________________________________________ BY: ________________________________________________
(Signature) (Signature)
______________________________________________ ___________________________________________________
(Print name) (Title) (Print name) (Title)
DATE: _____________________________________________________ DATE: ______________________________________________________
I further state that I have authority to act in behalf of the above named
If the Permittee cannot meet the University’s insurance requirements for facilities/premises use, a written request from the
Permittee explaining why must be attached. If the exposure to loss is substantially limited by the nature of the
facilities/premises use, the insurance requirement may be waived by the System Office of Risk Services Director or his/her
designee by signing below:
Commercial General Liability Insurance Waiver Request: Approved: NOT Approved:
Workers’ Compensation Insurance Waiver Request: Approved: NOT Approved:
Comments: ____________________________________________________________________________________________
Signature: ________________________________________________ Date: ______________________________________
System Office of Risk Services Director or Designee
Distribution: UA Facility manager Permittee
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University of Alaska Fairbanks
Protection Of Minors Certification Form
Groups, businesses, organizations, clubs, etc. who use UAF facilities and property for events, programs or activities
that include minors are required to certify that they have completed the following:
Reviewed and will follow the University of Alaska Fairbanks Protection Of Minors (POM) Policy
Completed a local, state, and nationwide criminal and sex offender background checks as described in the
POM Policy for any persons considered authorized adults according to the definition in the POM Policy
Trained all the adults that will be interacting with minors in the identification, prevention and reporting of
the sexual abuse of minors; (UAF training is available, please contact person below)
Ensured that no adults working with minors is convicted of a crime of violence, neglect, reckless
endangerment, or abuse against a minor or vulnerable adult; are a registered sex offender; have been
convicted of possession of child pornography.
Adhere to the contractor’s written policies related to the supervision of minors. At a minimum the
contractors supervision procedures should include: Minimum adult to minor ratios; How to supervise
minors during overnight activities; A signed Code of Behavior; How to supervise minors during activities
that are associated with water use, including, but not limited to pools, showers, bathing areas, swimming,
etc.; How to supervise minors during transition times, including drop-off and pick-up; Mandatory reporting
of incidents or allegations of sexual misconduct, (involving adults or minors) according to existing
University procedures.
You will also need to attach a certificate of insurance to this form that includes coverage for claims and losses of
abuse. If this is unavailable under a current insurance policy, it can be purchased at:
For questions, please contact
Elizabeth Hughes-Hageman
Protection of Minors Manager
| 907-474-6015
This letter is to certify that all Authorized Adults and Caregivers associated with ________________________
(see definitions in Protection of Minors Policy) have completed the aforementioned requirements prior to being
permitted to participate in programs that include Minors. I further certify that______________________________
has performed or reviewed background checks on all Authorized Adults/Caregivers and has not identified any
negative results.
List of Authorized Adults and Caregivers (list can be attached) or filled in below:
University of Alaska Fairbanks
Protection Of Minors Certification Form
Signature [Activity, Program Leader] ___________________________ Date___________________
Printed Name__________________________________ Title__________________________________
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Verbal abuse: degrade, threaten, cursing
Sexual abuse: inappropriate touch, exposing oneself, sexually oriented conversations
Mental abuse: shaming, humiliation, cruelty
Neglect: unreasonably withholding food, water, adequate clothing for conditions, or
16. Shall not allow Minors to engage in hazing, bullying, derogatory name-calling, games of “Truth or
Dare,” ridicule, or humiliation.
17. Shall report concerns or complaints about other adults or Minors in accordance with all reporting
I have read and agree to abide by the Code of Behavior requirements listed above. The Code of Behavior
shall be signed annually for any work involving Minors and again if working for another department,
camp, or program at UA.
Printed Name: _____________________________________
Signature: _________________________________________ Date: ___________________________
click to sign
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