estern University
Student Events/Field Trips
Acknowledgement and Assumption of Risk
Name of Participant: _______________________________________________
Address of Participant: _______________________________________________
Nature of Event/Field trip _______________________________________________
Date of event/field trip _______________________________________________
I am aware that during field trips or other excursions in which I am participating under the
arrangement of The University of Western Ontario, (_______________________________
______________________event/field trip), certain risks and dangers may occur, including
but not limited to the hazards of traveling, accidents or illness in remote places without
medical facilities, the forces of nature and travel by air, train, automobile or other means as
well as exposure to customs and practices of societies different from our own. Accordingly,
I understand that despite its efforts, the University may not be able to ensure my complete
safety at all times from such risks and dangers.
More particularly, I appreciate The University of Western Ontario does not carry accident or
injury insurance for my benefit and also that there may be certain matters for which I could
be held at fault personally if the accompanying circumstances do not relate to or arise from
my education or if my activities or conduct fall short of what would be considered a
reasonable standard for an individual in my position. In these cases I agree to be
accountable in all respects for my own actions and not to ask the University or its
employees to accept the consequences thereof; further, I agree to be responsible for any
claims made against the University in relation to such actions.
I acknowledge that I have been advised by The University of Western Ontario of such risks
and dangers as well as the need to act in a responsible manner at all times. My signature
below is given freely in order to indicate my understanding and acceptance of these
realities and in consideration for being permitted by the University to participate in the
above mentioned event/field trip.
________________________________ ________________________________
Signature of Participant Signature of Witness
......page 2 - cont=d from previous page - Acknowledgement and Assumption of Risk
I am aware that the University is providing transportation to and from the event/field trip
site. I have chosen to travel to and from the field trip site using alternate
I freely accept and fully assume all such risks, dangers and hazards and the possibility of
personal injury, death, property damage or loss, resulting therefrom.
________________________________ ________________________________
Signature of Participant Signature of Witness
This agreement must be completed in full, signed, dated, and witnessed before the
participant may participate in the event/field trip.
The information on this form is collected under the authority of the University of Western Ontario Act, 1982, as
amended, and is needed for the administration of field trips. If you have any questions about the University’s
collection, use, or disclosure of this information, please contact the Corporate Insurance Administrator,
Support Services Building, Room 5100 (tel: 519-661-2111 x81135).
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