Consent-to-Participate-and-Release-2020-1.pdf

Northeastern University v. 1/2/2020 Page 1 of 2

Northeastern University

Consent to Participate & Release of Liability

PARTICIPANT’S NAME:_____________________________________________ AGE:________________________

ADDRESS:________________________________________________________________________________________

CITY: STATE:________ZIP:_____________

ACTIVITY:____________________________________DATE(S) OF ACTIVITY:________________________________

I, the undersigned participant (or participant’s parent/guardian, if the participant is under the age of 18)

understands that this is a legally- binding Release of Northeastern University.

I request permission for the participant to participate in the Activity. In consideration of being

granted this permission, I agree as follows:

1. Voluntary Activity. I understand and agree that participation in this Activity is purely voluntary

and is not required by Northeastern University.

2. Acknowledgment of Risk. I recognize and appreciate the dangers, hazards, and risks of the

Activity which could include serious or even mortal injuries and property damage. I attest that I have

fully considered the risks and hazards, and I agree that I have individually assumed the risks involved

in this Activity.

3. Fitness to Participate. I hereby represent that the participant is physically and mentally able

to participate in the above referenced Activity and has no health problems which would present a risk

to the participant, or others, in participating in this Activity. I certify the participant has been seen by

a healthcare provider within the last year.

4. Compliance with Rules. I understand that the participant is required to abide by the rules of

Northeastern University, as well as any rules of conduct promulgated by the sites the participant may

visit as a part of participant’s participation in this Activity, and that the rules of conduct promulgated

by the sites and facilities will apply in addition to Northeastern University’s rules. I understand that if

the participant fails to follow all applicable rules that Northeastern University shall have the right to

terminate the participant’s participation privileges immediately and that further actions will be taken

if necessary.

5. Emergency Medical Treatment. I authorize the Released Parties (defined below) to transport

the participant to, and to authorize on participant’s behalf emergency medical treatment if necessary,

and I understand and agree that such action shall be subject to the terms of this Release. I understand

and agree that the Released Parties assume no responsibility for any injury or damage which might

arise out of, or in connection with such authorized emergency medical treatment or transport.