Please enable JavaScript in your browser to complete this form.Name *FirstLastBirthdate *Drury ID Number *Cell Phone Number *Emergency Contact Name *FirstLastEmergency Contact Phone Number *For which event are you registering? *Summer 2019 White Water tripLiability Form"I am familiar with the hazards of the above activity and further have been advised by the instructors and staff at Drury University of the dangers of such activity, and any necessary travel involved." *YesNo"I recognize the potential hazardous nature of the activities in which I may engage and agree to exercise necessary caution and to obey the instructions of all supervisors. The hazards of this activity have been weighed by me, and I accept them in consideration for being permitted to participate in this Drury University activity. I agree that Drury and its agents, servants and employees do not assume and custodial responsibility for me and are not liable to me in any way." *YesNo"I understand and acknowledge that Drury may utilize volunteer drivers or volunteers for other purposes as part of this activity, and I have no objection to the use of such volunteers." *YesNo"I agree to defend, hold harmless, indemnify, release and forever discharge Drury University, its trustees, officers, directors, employees, agents and all those claiming by, through, or under Drury University from any and all claims, demands, actions, causes of actions, costs, or damages, including claims involving Drury University's own negligence, arising from or caused by my participation in the activity, including related travel and contact with volunteers. I agree and understand that this liability waiver and indemnification will extend beyond the dates of this agreement. I intend this waiver, release and indemnification to be legally binding on my heirs, executors, administrators, personal representatives, estates, assigns and all others claiming by, through, or under me." *YesNo"In case of emergency, I understand that every effort will be made to secure proper treatment. I hereby give permission for such treatment. My personal health and accident insurance covers any accident or illness which I may incur during this activity. I personally guarantee payment of any cost or other liability incurred during treatment." *YesNo"I have read this release prior to signing it, and I fully understand it. I know that this document binds me and all those claiming under, through, or on account of me." *YesNo "I certify that the information listed above is true. My typed name verifies that I agree to and will comply with the previous statements." *YesNoDigital Signature *Submit
