Academic Year 2000-1
Hostos Community College Release
WAIVER OF LIABILITY
AND HOLD HARMLESS AGREEMENT ("Release")
1. In consideration for my participation in the _____________________ (the "Program"), I hereby agree and covenant not to sue, and to release and discharge Hostos Community College, The City University of New York, The Board of Trustees of the City University of New York, the State of New York, the City of New York and all of their respective officers, servants, agents or employees (hereinafter referred to as "Releasees") from any and all liabilities, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage or injury, including death, to me, or to any property belonging to or controlled by me, whether caused by the negligence of the Releasees, or otherwise, while traveling to/from or participating in the Program, or while in, on, upon or near the premises where the Program is being conducted.
2. I further hereby agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs, including court costs and attorneys' fees, that they may incur due to my participation in the Program, whether caused by negligence of Releasees or otherwise.
3. I understand that I am responsible for my behavior at all times. If, in the view of a staff member conducting any activity of the Program, I engage in behavior which presents a danger to myself or to others, I understand that appropriate steps will be taken to protect all involved.
4. It is my express intent that this Release shall bind my heirs, assigns and personal representatives.
5. I hereby agree that this Release shall be construed in accordance with the laws of the State of New York.
6. I hereby consent and grant permission should the necessity arise, to receive medical treatment and/or hospital services as ordered or recommended by a qualified physician, including the administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination, or other hospital services.
In signing this Release, I acknowledge and represent that I have read it in its entirety, understand it and voluntarily sign it as my own free act and deed; that no oral representations, statements, or inducements not contained herein have been made to me by any of the Releasees; that I am at least eighteen (18) years of age and fully competent; and I execute this Release fully intending to be bound by same.
___________________________________ _______________________________________
Print Name (Nombre) Sign name (Signatura)
___________________________________ _______________________________________
Home telephone number Work telephone number (Numero de
(Numero de telefono de la casa) telefono del trabajo)
___________________________________ _______________________________________
Name of emergency contact Phone number of emergency contact
(Nombre del contacto de emergencia) (Numero de telefono del contacto de emergencia)
List any medical conditions, medications and/or dietary needs you have (Condiciones medicales, remedios, o alergias):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
A note signed by a doctor must be submitted that indicates the names of any medications that you must take during the course of the Program day and the dosages.
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