STANFORD UNIVERSITY

Waiver

Statement of Personal Responsibility

I, the undersigned, who is at least 18 years of age, desire to participate in the Stanford _________________________ program, and do hereby declare that I have read, understood and accepted the following:

The following activity ______________________________ necessarily exposes participants to risk. There exist inherent safety hazards in the physical activities undertaken by all Stanford students and instructors. I am aware of and accept these risks and dangers to life and limb as an unavoidable part of my voluntary participation in Stanford program called _____________________________ .

I am at all times responsible for my own safety when I participate in any Stanford activity or outing.

I hereby waive, for myself and for anyone else claiming through me, any and all rights and claims of any nature that I may have against Stanford University, the Office of Student Activities, ____________________________ , and any of its participants, for and against any and all injuries or damages of any nature, including death, while voluntarily taking part in a Stanford event.

I agree to pay any reasonable cost to repair or replace any Stanford equipment lost or damaged by myself or through my actions, whether by accident or negligence. The determination of whether to replace or repair damaged equipment shall be made by the Stanford __________________________ instructors/sponsors. I will not be responsible for normal wear and tear on Stanford equipment.

SAFETY IS THE PRIMARY CONCERN OF THE STANFORD ____________________________ PROGRAM. IN SIGNING THIS WAIVER, I ACKNOWLEDGE THAT I AM AT LEAST 18 YEARS OF AGE AND THAT I CHOOSE TO PARTICIPATE SOLELY AT MY OWN RISK.

__________________________________________
(Name of participant)

__________________________________________
(Signature of parent or legal guardian if participant is under 18)

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Date