ࡱ> CEBA -bjbj 4.hhr& & <^fD5$$ "Q==== =PoPG:.0^#*##Y"{YYYBYYY^====#YYYYYYYYY& X ~:  Agreement for Assumption of Risk, Indemnification, Release, and Consent for Emergency Treatment I, (print name), age , desire to participate voluntarily in recreational activities at the 鶹Ƶ  FORMTEXT Eau Claire. I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT  FORMTEXT      , AT TELEPHONE NUMBER  FORMTEXT      . Assumption of Risks: I understand that physical activity related to  FORMTEXT      , by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Some of these involve strenuous exertions of strength using various muscle groups, some involve quick movement involving speed and change of direction, and others involve sustained physical activity, which places stress on the cardiovascular system. The specific risks vary from one activity to another, but in each activity the risks range from: 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as fractures, internal injuries, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I understand that the University has advised me to seek the advice of my physician before participating in this activity. I understand that I have been advised to have health and accident insurance in effect and that no such coverage is provided for my by the University or the State of Wisconsin. I KNOW, UNDERSTAND, AND APPRECIATE THE RISKS THAT ARE INHERENT IN THE ABOVE-LISTED PROGRAMS AND ACTIVITIES. I HEREBY ASSERT THAT MY PARTICIPATION IS VOLUNTARY AND THAT I KNOWINGLY ASSUME ALL SUCH RISKS. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Hold Harmless, Indemnity and Release: In consideration of permission for me to voluntarily participate in  FORMTEXT      , today and on all future dates, I, for myself, my heirs, personal representatives or assigns, agree to defend, hold harmless, indemnify and release the Board of Regents of the University of Wisconsin System, the University of Wisconsin   FORMTEXT Eau Claire, and their officers, employees, agents, and volunteers, from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from my participation in the above-listed program. This release includes claims based on the negligence of the Board of Regents of the 鶹Ƶ System, the 鶹Ƶ  FORMTEXT Eau Claire, and their officers, employees, agents, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence. I UNDERSTAND THAT BY AGREEING TO THIS CLAUSE I AM RELEASING CLAIMS AND GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY RIGHT TO SUE. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Consent for Emergency Treatment: I authorize the 鶹Ƶ  FORMTEXT Eau Claire aefghkp  ּtk[tjthoh CJUhoh CJjhoh CJUhoh]QCJhohYCJ hYCJ h]QCJ h3CJjh CJUjh CJU h CJhChC>*CJh]Qh]Q>*CJ hISCJ hjCJ h*7TCJ hoCJ h}qMCJ huzCJ h}qMCJefgh b d f QRpq$a$gdISgdCgdCgdIS$a$$a$gdY       8 : N P R T V X Z \ ^ ` b d f z    ༬ŝwshwZZjh UmHnHuj\h Uh jh Uh}qM hIS5 h}qM5hoh}qM5>* h*7TCJ hISCJhohCCJjhoh CJUhoh CJhohYCJhohjCJhoh]QCJjhoh CJU$jhoh CJUmHnHu#      R = = =op=$%=OQR]ckopq޺޲ޫ hC5CJ h]>T5CJ h5CJ hIS5CJhChC>*h OhC>*hhoh9)5CJaJhoh}qM5CJaJhISh}qMh]Qjh Ujh UmHnHu7  ./0:;<  ʾueeeee^X hUAgCJ h}qM5CJjh CJUmHnHujh CJU h CJjh CJU h]>TCJ hISCJ h}qMCJ hCJhoh>*CJhoh}qM>*CJhoh}qM5>*CJ h*7T5CJh]>Th]>T5>*CJ hIS5CJ h5CJh]>T5>*CJhChC5>*CJ   '7=?b +lo{|꛴ƏwwwwwwhohJ5CJaJhohY5CJaJhoh9)5CJaJ h7~CJjh CJU hUAgCJ hISCJ hCJ hoCJ h}qMCJhyCJmHnHujDh CJU h CJjh CJU h]>TCJ hyCJ. 2OQRT[_`abĻЯztnhbhXR h CJjh CJU hyCJ h]QCJ h}qMCJ hoCJhoho>*CJhoh}qM>*CJhoho5>*CJhoh}qM5>*CJh*7T5>*CJh]>Thj5>*CJhj5>*CJhChj5>*CJ hj5CJhChj>*h Ohj>*hjh hCJhohCJaJ2`ab5-6-T-U-v--$a$gd*7Tgdjgdjgd,F,,3-5-6-A-F-G-O-S-T-U-v--------Ϻ~h]>Thj5>*CJhj5>*CJhChj5>*CJ hj5CJhChj>*h Ohj>*hj h}qM5CJhUAgh}qM5;CJaJ h}qMCJU h]QCJhyCJmHnHujh CJUj,h CJUnd its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: 2&P:p*7T/ =!"# $ % tDText1tDText2tDText4tDText5tDText6tDText7tDText8tDText9x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH 8`8 Normal_HmH sH tH >@>  Heading 1$$@&a$5BB  Heading 2$$@&a$5CJ<@<  Heading 3$@&5CJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 0>0 Title$a$52B@2 Body TextCJ<P@< Body Text 2$a$CJH"H o Balloon TextCJOJQJ^JaJN/1N oBalloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y r!.  - - BNT   rFTFTFTFTFTFTFTFT8@0(  B S  ?Text1Text2Text4Text5Text6Text7Text8Text9C tU  tFQGQAAtJJt9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace !t[]7 9 EGt3333BU  s  f f tBU    s  f f t"!tJok9$*6}qM*7T]>TUAgj7~uzWs3@C^T69)N Oo VD O ]QSYtISyrt@OOOOL r@ @(@X@UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"h3'3''K 'K !20kk3Q@P?@*!xx2# /Medical Authorization/Emergency Medical Release Health PowelDrollinger, Brian K. Oh+'0 4@ ` l x 0Medical Authorization/Emergency Medical ReleaseHealth Powel Normal.dotmDrollinger, Brian K.3Microsoft Office Word@G@n@roP@ioP'K  ՜.+,00 hp  Northeastern Illinois Univk 0Medical Authorization/Emergency Medical Release Title !"#$%&'()*+,-./013456789;<=>?@ADRoot Entry FPoPFData 1Table #WordDocument4.SummaryInformation(2DocumentSummaryInformation8:CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q