STUDENT’S FULL NAME: ___________________________________________________

CLASS TITLE: (check those that apply)

The undersigned does hereby release and discharge the instructor, assistant(s), and property for any and all claims, demands, causes of action, damage, loss of services, costs and expenses in any way resulting from any and all injury to person or property arising directly or indirectly out of the student’s participation in the above activity, including any negligence of the instructor.
Further, the undersigned agrees to indemnify and hold forever harmless instructor, assistant(s), and property from any and all injuries, damages, costs, attorney’s fees whatsoever which may arise out of the student’s participation in the above activity, including any negligence on the part of the instructor.
The undersigned further consents and authorizes the instructor on the undersigned’s behalf to obtain any necessary medical treatment or hospitalization or such other care necessary for the health and welfare of the named student, and the undersigned agrees to be responsible for and pay the costs of such medical treatment or hospitalization. This release of liability and indemnification agreement shall be binding on the heirs, successors and personal representatives of the student and the undersigned.
I have read the foregoing release of liability and the indemnification agreement and acknowledge that the provisions are contractual and not a mere recital, and I understand I am bound by the terms hereof by placing my signature hereon.

(If the student is under the age of 18, a parent/guardian must also sign below to consent and grant permission for named student to participate in the above listed activity.)

_________________________________________________ Date: ______________________________
Parent/Guardian Signature

_________________________________________________
Parent/Guardian Name (please print clearly)

_________________________________________________ Date: ______________________________
Student Signature

_________________________________________________
Student Name (please print clearly)