ASSUMPTION OF ALL RISKS OF INJURY AND WAIVER OF RIGHTSW A I V E R
There are risks of injury, both serious and minor, associated with flying with _____________________, and the activities related thereto, both now and in the future. The risks include, but are not limited to, injury to the head, neck or spine (including brain damage and paralysis); mental and emotional injuries; injury to the muscular or skeletal systems; injury to internal or external organs; loss or damage to sight, hearing or teeth; long-term or short-term disability; loss of income, career opportunities, and enjoyment of life; pain and suffering; scarring or disfigurement, and death.
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It is the responsibility of each individual, student and/or participant to know his or her own general state of health and well being, and therefore to be able to certify knowledgeably that he or she is physically fit to fly with ______________________________, and participate in the activities related thereto, both now and in the future.( ) initials
It is also the responsibility of each individual, student and/or participant to have health insurance coverage sufficient to cover all medical, dental, and any other health care expenses for all injuries, minor or catastrophic, sustained or incurred as a result of flying with ______________________________ or participating in the activities related thereto, both now and in the future.( ) initials
Therefore, as a pre-condition to being permitted to fly with ______________________________ and participate in the activities related thereto, both now and in the future, I agree to make an informed and educated choice to fly or not to fly with ______________________________, and to participate or not participate in the activities related thereto, both now and in the future. My signature below signifies my recognition of the risks of injury involved in flying with ______________________________, and participating in the activities related thereto, both now and in the future, and my informed consent to voluntarily assume them.( ) initials
Before releasing _______________________ and the Board of Trustees of the Leland Stanford Junior University, its officers, agents, employees, volunteers and students, from any and all actions, claims or demands related to any injuries I may sustain, including death, as a result of flying with _____________________ and/or participating in the activities related thereto, both now and in the future, I have given serious consideration to the ramifications of this assumption of all risks of injury and waiver of rights. I understand that the causes of possible injury and death are many, including but not limited to injury or death from bodily contact, incidental to or inherent in the nature of flying, regardless of physical or environmental conditions; injury or death due to improper instructions or the lack thereof by ______________________________, his officers, agents, employees, volunteers, or students and failure to properly maintain or fly the aircraft, among others.( ) initials
I acknowledge the risk of injury that may result from flying with ______________________________ and/or participating in the activities related thereto, both now and in the future, and am willing to and hereby do voluntarily assume all risks of injury associated with my choice to fly with ______________________________, and/or participate in the activities related thereto, both now and in the future.( ) initials
I assume full responsibility for assuring that I am mentally competent, in good health, and have no medical conditions which might make flying with ______________________________, or participating in the activities related thereto, both now and in the future, inadvisable.( ) initials
I agree not to fly or attempt to fly with ______________________________ , or participate in the activities related thereto in the future, unless I am at that time mentally competent, in good health and have no medical condition which might make flying with ______________________________, or participating in the activities related thereto inadvisable.( ) initials
I am aware that flying with ______________________________ will expose me to risks of injury, minor or serious as described in this assumption of all risks of injury and waiver of rights. I accept and assume all risks, known or unknown, listed or unlisted, to which I may be exposed, or that may result from my voluntary decision to fly with ______________________________ and/or participate in the activities related thereto, both now and in the future, regardless of cause.( ) initials
I acknowledge my responsibility to acquire health insurance coverage sufficient to pay for all medical, dental, or other health care services needed or required as a result of any injury, minor or catastrophic, sustained or incurred as a result of flying with ______________________________ , or participating in the activities related thereto, both now and in the future, and hereby certify that on the date noted below, I have such insurance coverage in effect and will maintain such coverage while flying with ______________________________ and participating in the activities related thereto.( ) initials
In consideration of The Board of Trustees of the Leland Stanford Junior University, its officers, agents and employees ’s permitting me to fly with ______________________________ and/or participate in the activities related thereto, both now and in the future, I agree, for myself, my heirs, and/or my legal representatives, to release _________________________ and the Board of Trustees of the Leland Stanford Junior University , its officers, agents, employees, volunteers, and students, from any action, claim, or demand that I, my heirs, or my legal representatives have or may have, for any and all injuries I may suffer or sustain, regardless of cause or fault, including any negligence of the released parties, as a result of my voluntary decision to fly with ______________________________ and/or participate in the activities related thereto, both now and in the future, on and off campus.( ) initials
In further consideration of the Board of Trustees of the Leland Stanford Junior University , its officers, agents, employees, volunteers, and students, permitting me to fly with ______________________________ and participate in the activities related thereto, both now and in the future, I knowingly and intentionally give up and waive any legal right that I, my heirs, or legal representatives have or may have against _______________________________ and the Board of Trustees of the Leland Stanford Junior University, its officers, agents and employees, for any action, claim, or demand that I, my heirs, or my legal representatives, have or may have for any injuries I suffer or sustain, regardless of cause or fault, including any negligence of the released parties, as a result of my voluntary decision to fly with ______________________________ and/or participate in the activities related thereto, both now and in the future, on and off campus.( ) initials
I knowingly intend my signature on this assumption of all risks of injury and waiver of rights to be a complete defense to any legal proceeding that may be brought by me, anyone on their own or on my behalf for any injury I may suffer or sustain as a result of voluntarily flying with ______________________________ and participating in the activities related thereto, both now and in the future, and further intend this assumption of all risks of injury and waiver of rights to be a complete and total release of liability for all negligent acts, failures to act, or breaches of duty owed to me by the released parties, which result in injury to me or my death as a result of my voluntary decision to fly with ______________________________ and/or participate in the activities related thereto, both now and in the future, on and off campus.( ) initials
I intend this assumption of all risks of injury and waiver of rights to cover all flights with ______________________________, and all of the activities related thereto, both now and in the future, regardless of date, time, or location.( ) initials
I certify that I am 18 years of age or older, that I am legally competent and capable of executing this Assumption of All Risks of Injury and Waiver of Rights, that I have read it, understand it, and have made a conscious decision to sign it of my own free will.
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