This acknowledgement is to be completed by each student who is a member of an ongoing team sport event such as (but not limited to) Football, Basketball, Table Tennis, Chess) . If the student is participating in more than one event then the form must be completed (only once) for each sport. It must be returned to the Staff Person in Charge prior to the commencement of the excursion(s). Please note that failure to submit this form may jeopardise the p articipant’s ability
UOWD Women Basketball team
Name of Team/Sport __________________________________________________________________________
Student Name: __________________________________________________________________________________________ PUNE INDIA
Student Number: ____________________ Excursion Destination: _______________________________ Date ________________
Please tick the relevant boxes and sign the form.
I have been provided with a copy of the General Excursion Information Notice and am aware of the foreseeable hazards associated with participating in this ongoing event .
I understand that all UOWD policies and rules apply during any authorised excursion. I understand that breech of policies or rules of conduct may result in disciplinary action. I have/will seek appropriate medical advice regarding any medical condition(s) I have, or may develop and the risks associated with my participation on the excursion and have, if necessary a Medical Clearance to this effect.
I have advised the excursion coordinator/supervisor of medical advice sought, that will assist in the management of my medical condition whilst away on the excursion
Transport to Excursion
I understand and accept that if I drive to or from an excursion, I will be travelling at my own risk. I acknowledge and accept that, to the full extent permitted by law, the University of Wollongong in Dubai, on behalf of itself and its officers, employees and agents expressly disclaims any and all liability for injuries, damages, loss or expense including, but not limited to, any liability arising directly or indirectly out of any accident or injury suffered by me during the excursion or travelling to and from the excursion.
I release and indemnify the University of Wollongong in Dubai, its officers, employees and agents on a full indemnity basis against all actions, claims, proceedings and demands that my be made against them for injury, damage, loss or expense (including death, permanent incapacity or financial loss) arising out of my attendance at any UOWD excursion. This indemnity covers all claims and liability, however, described and however arising and includes, but is not limited to, any accident or injury suffered by me during any excursion or travelling to and from any excursion. Further this indemnity covers claims by and liability to, anyone who claims through me.
Signature: ____________________________________________________ In case of an emergency, the following person is to be contacted: EMERGENCY CONTACT DETAILS:
For participants under the age of 18 (Parent/Guardian must sign) ________________________________________________________________________________________________ Parent/Guardian Name:
_________________________________________________________________________________________ _______ Signature: