Student Name:
Address:

As a Senior College student at USM, Lewiston-Auburn College, being of legal age, acknowledge, declare, and agree as follows:

1. That I have voluntarily agreed to participate in ______________________________________
   from ________ through _______, 20__ sponsored by the University of Southern Maine, Lewiston-Auburn College and in consideration of being permitted to participate in this program, do voluntarily execute this “Release and Assumption of Risk” on behalf of myself, my heirs, and next-of-kin, my personal representatives and my estate.

2. That the University of Southern Maine System (hereinafter referred to as the “University”) has apprised me that there may be dangers and hazards inherent to participants in this program and that I personally recognize and appreciate that such dangers and hazards exist. I understand that the University is not a guardian of my safety and I accept and assume full responsibility for all harm and injury, of every nature, including death, which may occur to me or which I may suffer, and for all damages or loss to any personal property owned by me, while I am participating in these programs and during all travel and transportation to, from, and within the United States or any other location, and, in furtherance thereof, I agree to indemnify and hold harmless the University, its Trustees, faculty, employees and students from and against any and all claims, demands, actions or causes of action, on account of damage or loss to my personal property, my personal injury, or death, which may occur or result directly or indirectly from my participation in these programs, and not as a direct result of any negligent act of the University, its Trustees, faculty, employees or agents.

3. I declare that I am able to physically withstand and cope with the indicated rigors of these programs, with or without an accommodation. If an accommodation is needed, I will contact the host location coordinator.

4. I request that this “Release and Assumption of Risk” be construed and interpreted pursuant to the laws of the State of Maine, and if any portion thereof is held invalid, I request the remainder continue in full force and effect.

5. I declare that I completely understand and have fully informed myself of the terms and conditions of this “Release and Assumption of Risk” by having read it, or having it read to me, before signing.

Assented and agreed to on this ___________ day of ______________, 20___.

Signed: _______________________________________________________