"ACKNOWLEDGMENT OF RESPONSIBILITY LIABILITY WAIVER Queen s University Exchange Program"
ACKNOWLEDGMENT OF RESPONSIBILITY & LIABILITY WAIVER Queen's University Exchange Program ACKNOWLEDGMENT OF RESPONSIBILITY & LIABILITY WAIVER I understand that participation in a Queen's University Exchange Program will take me away from campus for an extended period of time. During this period I understand that I will be exposed to risks to my person and I am prepared to accept these risks. In consideration of the opportunity provided by Queen s University to participate in this program, I hereby release and hold harmless Queen's University, its agents and employees, from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer, as a result of my participation in this program due to any cause whatsoever including, but not limited to, negligence, breach of contract or breach of any statutory or other duty of care, delay, expense resulting from events beyond their control, acts of God, war, civil unrest, sickness, transportation, scheduling and government restrictions or regulations. I further understand that it is my responsibility to abide by all applicable University policies, the laws of the host country, and to ensure that I have adequate medical, personal health, dental and accident insurance coverage, as well as protection of my personal possessions. I recognize that in the event of a general civil emergency, the University, through the Government of Canada, will endeavour to assist its students. It is understood that my supervisor or exchange coordinator can require my withdrawal from the program for reasons of illness or conduct unbecoming a student of Queen's University and will be the sole authority in exercising that judgment. For the purpose of this waiver, the period of time I am participating in a Queen's University Exchange Program will correspond to the academic program dates of the institution I am attending. I understand that this agreement cannot be modified or interpreted except in writing by Queen's University and that no oral modification or interpretation shall be valid. I appoint the following person my Designated Next of Kin and authorize the University to contact that person for or with information about me in my absence. Name: ____________________________________________________________________________ Address: __________________________________________________________________________ Telephone: _________________________________________________________________________ Date: ________________________________ I have fully informed my Next of Kin regarding all aspects of my proposed study including the nature of any possible risks. I ACKNOWLEDGE MY OBLIGATIONS AND RESPONSIBILITIES. Participant Name: ___________________________________________________________________ Address: http://law.queensu.ca/students/International/waiver.htm (1 of 2)9/28/2006 3:02:30 PM ACKNOWLEDGMENT OF RESPONSIBILITY & LIABILITY WAIVER ___________________________________________________________________________ Telephone: _________________________________________________________________________ Signature: ________________________________________ Witness: __________________________________________________________________________ Date: ____________________________________ http://law.queensu.ca/students/International/waiver.htm (2 of 2)9/28/2006 3:02:30 PM