I hope the formatting comes out ok. She had to sign one of these so the Institution of Higher Learning covered is ass with all the right paperwork. They will wash their hands of her as soon as they can.
WAIVER, RELEASE, AND INDEMNITY AGREEMENT
Please attach to your contract or return to the Academic Deans Office, Library 2217.
The Evergreen State College 98505 (Revised 2/28/03)
Read carefully before signing.
I, ___________________________________(Evergreen ID#____________________), hereby affirm that I have
(please print)
voluntarily enrolled in (program/contract title) ______________________________________________________
sponsored by (faculty)
__________________________________________________________________________;
in (location/country)
___________________________________________________________________________.
I certify that I am cognizant of inherent dangers associated with participating in this program/contract including accidents, illness, civil strife, terrorism, and any other harm, injury, illness or damage which may befall me. (_____)
I understand that neither The Evergreen State College (Evergreen), its instructors nor any of its agents serve as
guardians or insurers of my safety.
I understand that Evergreen does not provide any insurance for my protection
and acknowledge responsibility for providing my own insurance against these risks.
I further acknowledge and understand that my decision to take part in this program/contract is not a requirement
for completing my degree at Evergreen. I understand that other options are available, which would enable me to earn
my degree.
I understand that it is my responsibility to have a medical examination to assure myself that I am physically fit
and capable of participating in this program/contract, and I assume all risks for failing to do so. I verify that I have
received all the recommended vaccinations appropriate to my travel destination.
I understand that if I am a student with a documented disability that it is my responsibility to have an
accommodation plan on file with the Office of Students with Disabilities in a timely manner – at least three months
before departure.
In consideration of being allowed to participate in this program/contract, I hereby personally assume all risks in
connection with said program/contract, and I further release and hold harmless the State of Washington, Evergreen,
Evergreen faculty and agents for any harm, injury or damage which may befall me, including all risks connected
therewith, whether foreseeable or not.
Further, I understand and agree that neither the State, Evergreen, instructors, nor agents thereof, may be held liable by me or my family, estate, heirs, or assigns, in any way for any negligence in
connection with the program/contract which may result in my injury, death, or other damages.
I further state that I am eighteen years of age or older and legally competent to sign this affirmation and release;
that I understand the terms herein are contractual and not a mere recital; and that I have signed this document and
knowingly assume the risks inherent in this program/contract. The terms of this document shall serve as a release and
assumption of risk for myself, my heirs, executor and administrators and for all members of my family.
I have fully informed myself of the contents of this affirmation and release by reading it before I signed it. I
acknowledge that this release must be completed, signed and submitted before departure. I have read and completed
the study abroad pre-departure check list.
I have attached a copy of the State Department Travel Advisory (
http://travel.state.gov/travel_warnings.html#i) for the
countries I will be visiting and understand it. (_____)
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON
THAT THE FOREGOING IS TRUE AND CORRECT.
(Student’s Signature and date) City, state where signed
Parent/Guardian signature required for students under age 18.
Parent/Guardian Signature(s) and date City, state where signed
Dean: I have discussed the above and the State Department Travel Advisory with the student.
__________________________________________
Dean Signature and date