Prepared and approved by
Office of General Counsel
Eastern Illinois University
(Rv. 10/06/03)

This is a legally-binding Liability Release, Waiver, Discharge, and Covenant Not to Sue made by me, [insert name of individual] (hereinafter referred to as “Releasor”) to  THE BOARD OF TRUSTEES OF EASTERN ILLINOIS UNIVERSITY (hereinafter referred to as the “University”).

I fully recognize that there are dangers and risks to which I may be exposed by participating in [insert name and type of activity] during/on [insert time period] .  The following is a description and/or examples of significant dangers and risks associated with this activity [insert description of risks below]:
.

I understand that the University does not require me to participate in this activity, but I want to do so, despite the possible dangers and risks and despite this Release. I, therefore, agree to assume and take on myself all of the risks and responsibilities in any way associated with this activity.  In consideration of and return for the services, facilities, and other assistance provided to me by the University in this activity, I release the University (and its governing board, employees, and agents) from any and all liability, claims and actions that may arise from injury or harm to me, including death, or from damage to my property in  connection with this activity.  I understand that this Release covers liability, claims and actions caused entirely or in part by any acts or failures to act on my part, including but not limited to negligence, mistake, or failure to supervise.

I assure the University that there are no health-related reasons or problems which preclude or restrict my participation in this activity.  I further assure the University that I have adequate health insurance necessary to provide for and pay any medical costs that may directly or indirectly result from my participation in this activity, and I will indemnify and hold the University harmless for any such medical costs. I understand that this Release means I am giving up, among other things, rights to sue the University, its governing board, employees, and/or agents for injuries (including death), damages, or losses I may incur.  I also understand that this Release binds my heirs, executors, administrators, and assigns, as well as myself.

I HAVE READ THIS ENTIRE RELEASE, I FULLY UNDERSTAND IT, AND I AGREE TO BE LEGALLY BOUND BY IT.

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Releasor's Signature                        Date  

WITNESSES:

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Witness Signature    

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Witness Signature
 
(If Releasor is under 18 years old, both parents or guardians must sign below.)

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Parent or Guardian Signature

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Parent or Guardian Signature