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Flying Samaritans at UCLA Clinic Participation Waiver and Media Release Form
Please fill out the following Clinic Participation Waiver and Media Release Form.
Email address *
Full Name (must be spelled correctly) *
University ID *
Clinic Participation Waiver *
In consideration of being permitted to participate in Flying Samaritans at UCLA Clinic in Colonia Margarita Moran, Mexico, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Flying Samaritans at UCLA and its agents from liability from any and all claims including the negligence of Flying Samaritans at UCLA and its agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation (including transportation, if applicable). Assumption of Risks: Participation in Flying Samaritans at UCLA clinic carries with it certain risks that cannot be eliminated regardless of the care taken to avoid injuries. Specific risks may vary, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such associated with slips and falls, and concussions to 3) catastrophic incidents including paralysis and death. I have read the paragraph and I know, understand, and appreciate these and other risks that are possible from my participation in the Flying Samaritans at UCLA clinic. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Indemnification and Hold Harmless: I also agree to indemnify and hold Flying Samaritans at UCLA, HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in Flying Samaritans at UCLA clinic and to reimburse them for any expenses incurred. Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Acknowledgement of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intend by my agreement to this condition to be a complete and unconditional release of all liability to the greatest extent allowed by the law.
Media Release Form *
The undersigned hereby authorizes the Flying Samaritans at University of California Los Angeles and their appointed agents to photograph, videotape, audio record, and/or televise the participant. While a participant in a Flying Samaritans at UCLA event, the undersigned agrees that Flying Samaritans of UCLA, its authorized agents, and assignees may use the photographs, videotapes, and/or audio recordings prepared there to reproduce, exhibit, publish, or distribute in such a manner as they deem fit.
Electronic Signature: Please Sign with Your Full Name (must be spelled correctly) *
By selecting the "I Accept" button, you are signing the Clinic Participation Waiver and Media Release Form electronically. You agree your electronic signature is the legal equivalent of your manual signature. By selecting "I Accept" you consent to be legally bound by the Clinic Participation Waiver and Media Release Form terms and conditions. You also agree that no certification authority or other third party verification is necessary to validate your electronic signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your electronic signature or any resulting contract between you and Flying Samaritans at UCLA.
A copy of your responses will be emailed to the address you provided.
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