North Arizona University Release Form is an undertaking signed and issued by the participant to waive any and all sorts of liabilities and claims arising due to personal injury, damage to property, and/or lives due to participation in certain activities.
Certain activities involve risk of injury and the participant undertakes this release form to offer substantial rights. The participant further declares that he/she signs the release form voluntarily. Furthermore, the participant agrees that the parties seeking the security from the claims do not undertake to provide medical assistance if any, required to the participant before, during, and after the participation in the event. Compensating and remitting the costs of such medical support and facilities will be the sole responsibility of the participant.
Before You Proceed
- Return duly completed and signed Release Form to NAU, Property and Liability Insurance Services, PO Box 4067, Flagstaff, AZ 86011.
- Parent’s or Guardian’s signature is necessary in case the participant is minor.
- Read the undertaking carefully before signing, accepting, and returning it.
- Mention the event name and date specifically for which you are signing the release form.
- Complete the release form duly before returning it.
- The release form is Contract with Legal Consequences.
- Type all inputs legibly.
Start by entering a name and/or description of the event in the foremost portion of the release form. Proceed with entering contact name, email address, and telephone number of the Department. Type the date of the event on the subsequent line. The next line requires the input of the participant’s legal name.
Read the undertaking on the following lines carefully and ask doubts/queries if any before proceeding to the next section of the release form. Understanding the consequences of accepting, signing, and returning the release form is very necessary, even from the legal standing.
Proceed with printing the name of the participant on the first line of the next block. Enter the mailing address followed by the name of the state and zip code. Mention the home phone number in the space provided for the same. Write the work phone number, if any. Type the emergency phone number in the space provided for the same.
Select if the participant is covered under health insurance from options A or B. Mark your choice in the respective box. Proceed with furnishing the name of the health insurance company followed by the policy number, group number, and ID number.
Sign in the space provided to accept and undertake the release form and enter the date in the next space provided for the same.
Parent’s or Guardian’s signature is necessary if the participant is under the legal age of 18 years. Complete filling the release form by entering the date in front of the signature of a parent or guardian. Filling this portion of the release form is only necessary when the participant is minor.
Arizona Liability Release Form 3
Text version of this Form
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RELEASE FORM
THIS RELEASE IS A CONTRACT WITH LEGAL CONSEQUENCES. READ IT CAREFULLY BEFORE SIGNING.
PLEASE PRINT CLEARLY
Event:
Dept Contact Name/E-mail/Phone#:
Location(s)/Date(s):
In consideration of being allowed to participate in any way in this event, program, and related activities, I: _______________________
Acknowledge and fully understand that I will be participating in activities that may or may not involve risk of serious injury,
permanent disability, property damage and/or death. These risks may result not only from my own actions, inactions, or
negligence, but also from the action, inactions, or negligence of others. Further, there may be other risks not known to me, or
not reasonably foreseeable, such as disability or death.
Assume all the foregoing risks and accept personal responsibility for any damages following any such injury, permanent
disability, property damage, or death.
Release, waive, discharge, and covenant not to sue the State of Arizona, the Arizona Board of Regents, Northern Arizona
University, their officers, employees, and agents, and their heirs, administrators, and executors, from demands, losses, or
damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the
negligence of any person or otherwise, for myself and my spouse, if any, and our heirs, successors, and assigns.
Understand that the State of Arizona, the Arizona Board of Regents, and Northern Arizona University do not provide medical
coverage to a participant if injured while participating in the event described above or attendant activities. Any medical costs
incurred as a result of this activity will be my financial responsibility.
ACKNOWLEDGE THAT I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I HAVE
GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.
Participant’s Name (print):
Mailing Address:
State: _____________ Zip Code: _______________ Home Phone Number:
Work Phone Number:__________________________ Emergency Phone Number:
Is this participant covered by health insurance? Yes No
Health Insurance Company:
Policy #: _________________________ Group#: __________________ ID #:
I verify that the above information is true and correct.
Date: _____________________________
Participant’s signature:
Date: _____________________________
Parent/Guardian’s signature (if participant is under 18 years of age)
Return Release Form to NAU, Property and Liability Insurance Services, PO Box 4067, Flagstaff, AZ 86011
11/4/ 10