Attachment 400.1
(Field Trips and Other Off Campus Activities)
Class: ____________ Semester: _________Description of Activity: ___________________
I am fully aware and acknowledge that there are inherent dangers and risks involved in the
field trip/activity which include, but are not limited to: ________________________
I understand that the University of Hawaii does not provide health insurance or otherwise
indemnify individuals with respect to injuries or other liabilities arising out of participation in
the field trip/activity.
I have read and understand any and all written materials setting forth the requirements for
my participation in the field trip/activity and I agree to strictly observe them.
In consideration of being permitted to participate and in full recognition of the inherent
dangers and hazards in this field rip/activity and during transportation to and from this offcampus
location, I voluntarily assume full responsibility for any loss, property
damage or personal injury, including death, that may be sustained as a result of my
participation. I, for myself, my heirs, personal representatives or assigns, hereby
release, waive, discharge and covenant not to sue the University of Hawaii, its
officers, employees and agents from any and all claims resulting in property damage
or personal injury or illness or death arising from my participation in the field
trip/activity or growing out of or caused by my acts or omissions during my
participation in the field trip/activity.
I also agree to DEFEND, INDEMNIFY AND HOLD HARMLESS the University of
Hawaii, its officers, agents and employees from and against any and all claims,
demands and actions or causes of action, on account of damage to personal
property, or personal injury or death which may result from my participation and
which result from causes beyond the control of, and without the fault or negligence
of the University of Hawaii, its officers or employees.
I have read the Assumption of Risk, Release, and Indemnity Agreement and
understand that I am giving up substantial rights, including the right to sue. I

acknowledge that I am signing the agreement freely and voluntarily.
I agree that if any portion is held invalid, the remainder will continue in full legal force and
________________________________________________________                             Date________________
Signature (Co-signature of parent or guardian required if under 18 years of age.)
Print Name








Student Information




Phone Number/Cell Number___________________________________________

Email address________________________________________________________

Emergency Contact____________________________________________________

Medical Conditions (anything that could effect your participation in this program):


Class affiliation_______________________________________________________


Brief Project Description________________________________________________


Community Partner_____________________________________________________