Northern Arizona University

ARIZONA BOARD OF REGENTS
FOR AND ON BEHALF OF
NORTHERN ARIZONA UNIVERSITY
Contracts, Purchasing and Risk Management

ASSUMPTION OF RISK, WAIVER, RELEASE, AND CONSENT FOR
NON-STUDENT MINOR PARTICIPATION

This NAU form is collected per state law and institutional policy for liability reasons. The information may be shared with the NAU Contracts, Purchasing, and Risk Management office as a matter of record. Questions about the information being requested can be directed to (928) 523-4557 or NAU-Insurance@nau.edu

 

Program Description:

Upward Bound Math & Science

 

Department Contact (name, e-mail, phone):

Chris Wilkens, chris.wilkens@nau.edu, 928.523.6986

 

Program Location:

Flagstaff Mountain Campus

Identification will be required to be shown to Program staff by the person who is picking up the Non-Student Minor. If the parent(s)/legal guardian(s) listed above is not the person picking up the Non-Student Minor, add name(s), relationship(s), and phone number(s) of other authorized individuals below.

I affirm that I am the adult parent or legal guardian of {main_name}, a Non-Student Minor under the age of eighteen (18), and I consent to their participation in this Program. In consideration of allowing Non-Student Minor to participate in this Program and related activities, I, on behalf of Non-Student Minor and for myself and my spouse, if any, and our heirs, successors, and assigns:

1. Acknowledge and understand that allowing Non-Student Minor to participate in the Program may involve a variety of activities. Such participation, particularly in field trips, “wilderness trips,” sports camps, and physical education, may involve risks, including but not limited to, serious personal injury, partial or permanent disability, sickness, disease or illness, property damage, and/or death. These risks may result from Non-Student Minor’s own actions or inactions, from the actions or inactions of others, or may be inherent to participating in the Program. I understand that I am responsible for ensuring that Non-Student Minor is properly prepared for all Program activities, and I represent that Non-Student Minor is in good health and is able to participate fully in all Program activities. If the Program is an on-line activity, risks include but are not limited to, data mining, phishing, viruses, malware, data breach of on-line information, cyberbullying, exploitation, cyber stalking, on-line grooming, cyber predators, and image replication. Knowing these risks may occur in an on-line Program, I choose to have Non-Student Minor participate in the Program. I also understand that Northern Arizona University is not an agent of and has no responsibility for any third party that may provide any services during the Program, including but not limited to, food, lodging, travel, and equipment associated with the Program. I acknowledge that Northern Arizona University has taken enhanced health and safety measures, in accordance with guidelines from the U.S. Centers for Disease Control and Prevention, in response to the COVID-19 pandemic. An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. By allowing Non-Student Minor to attend the Program at Northern Arizona University, I voluntarily assume all risks related to Non-Student Minor’s exposure to COVID-19.

2. Assume all of the foregoing risks and accept personal and financial responsibility for all damages for personal injury, partial or permanent disability, property damage, or death of Non-Student Minor, or caused by Non-Student Minor, to the fullest extent allowed by law.

3. Agree not to sue the State of Arizona, the Arizona Board of Regents, Northern Arizona University, their officers, employees, agents, and assigns, and waive all claims, demands, losses, or damages on account of personal injury, partial or permanent disability, property damage, or death, caused or alleged to be caused in whole or in part by the actions of any person or entity, to the fullest extent allowed by law.

4. Grant to Northern Arizona University and to its employees, agents and assigns the right to photograph Non-Student Minor and use the photo and or other digital reproduction of them or other reproduction of their physical likeness for publication purposes for use in connection with Northern Arizona University Programs, whether electronic, print, digital or via the Internet, so long as I have signed the Non-Student Minor Release Form.

5. Understand that the only medical treatment that will be provided by the Program is for such things as minor scrapes and bruises. Any medical costs, including emergency medical treatment that may be incurred as a result of Non-Student Minor’s participation in the Program will be my financial responsibility. I further understand that medical care facilities may not be immediately available and I accept the increased risk in the event of injury or death.

6. Hereby consent to Northern Arizona University and any appropriate medical facility, and/or to the physician(s) listed below, providing whatever medical services they may deem necessary for Non-Student Minor in the event of an emergency. I certify that I have adequate insurance and/or other means to pay for any costs and expenses related to these services and I agree to bear such costs and expenses in full.

7. Agree to review Program rules with Non-Student Minor and agree Non-Student Minor will comply with Northern Arizona University rules, standards, as well as any specific standards of conduct of the Program that may be provided. I understand that Non-Student Minor is not permitted to consume alcohol, possess/use weapons or illegal substances, or engage in sexual activities while participating in the Program. I understand Non-Student Minor may be removed from the Program for misconduct or failure to follow rules or instructions of Northern Arizona University or for any behavior detrimental to or incompatible with the standards of Northern Arizona University or the Program, and I understand that in that event I may not be entitled to a refund of any or all Program fees and costs.

8. Waive and release all claims against the State of Arizona, the Arizona Board of Regents, and Northern Arizona University, their officers, employees, agents, and assigns that arise at a time when Non-Student Minor is not under the direct supervision of Northern Arizona University or that are caused by Non-Student Minor’s failure to remain under such supervision or to comply with rules or instructions, to the fullest extent allowed by law.

9. Acknowledge and understand that either the Non-Student Minor or Northern Arizona University has the right to decline, decrease, or cease Non-Student Minor’s participation in the event of illness, injury or other medical condition.

10. Understand that Northern Arizona University may reduce or stop Non-Student Minor’s participation, in its sole discretion, in the best interest of safety or to aid in the well-being of other participants. Northern Arizona University may require further assessment and medical clearance from a physician prior to participation in the Program.

11. ACKNOWLEDGE THAT I HAVE CAREFULLY READ THE ABOVE ASSUMPTION OF RISK, WAIVER, RELEASE, AND CONSENT FOR NON-STUDENT MINOR PARTICIPATION FORM AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.

12. No oral or written representations can or will alter the contents of this document. I agree that this document shall be governed by the laws of the State of Arizona.

Title IX Travel - Blanket

I {parentslegalGuardians}, the adult parent or legal guardian, acknowledge that double or multiple occupancy may occur during the [Upward Bound Math Science Program] for travel and/or on-campus residency sponsored by Northern Arizona University (university). I understand the risks of a Non-Student Minor sharing a room with other Non-Student Minors, and I acknowledge that I have had a chance to read the university's Sexual Misconduct Policy. Knowing this, I voluntarily assume the risk and choose to have the Non-Student Minor participate in the Program.

ARIZONA BOARD OF REGENTS
FOR AND ON BEHALF OF
NORTHERN ARIZONA UNIVERSITY
Contracts, Purchasing and Risk Management

BEHAVIORAL EXPECTATIONS FOR NON-STUDENT MINORS

This NAU form outlines the behavior expected by NAU and Upward Bound Math & Science of your minor while participating in our programs, events, etc. Please be sure to emphasize thee expectations to your minor.

 

THIS DOCUMENT HAS LEGAL CONSEQUENCES. IT MUST BE COMPLETED AND SIGNED PRIOR TO PARTICIPATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.

If not defined within the form, all capitalized words shall have the meaning as set forth in the Northern Arizona University Supervision of Non-Student Minors Policy.

 

Northern Arizona University is committed to providing a safe, enjoyable, and healthy learning environment for all NonStudent Minors involved in Programs on its campus to include virtual or on-line programs. Northern Arizona University encourages an environment of mutual respect. In order to promote the health and safety of all involved, participation by a Non-Student Minor may be terminated at the discretion of Program staff if the Non-Student Minor does not abide by these expectations.

Non-Student Minors are expected to follow all Northern Arizona University policies as well as the guidelines listed below:

1. Work cooperatively and respectfully with other Participants, volunteers, faculty, and staff.
2. Follow established Program rules and directions.
3. Use appropriate language and behavior at all times. Language or behavior that is abusive, harassing, or threatening may result in removal or suspension from the Program.
4. Use all Northern Arizona University property and materials appropriately. Charges may be incurred in the event of misuse or damage.
5. Dress appropriately for the activities as directed by Program staff, including the use of safety gear where required.
6. Remain on property where the Program is held or with the group at all times. Participants should not leave the property or group without prior notification and authorization from Program staff.
7. Obey all local, state, and federal laws.
8. Do not bring any prohibited items to Program activities and events, including for example tobacco, alcohol, drugs, illicit material, or weapons. Northern Arizona University’s campus and facilities are weapons and tobacco-free.
9. Do not host guests in Northern Arizona University-owned or provided overnight accommodations without express permission from Program staff.
10. Report to Program staff any abuse or neglect committed against any Non-Student Minor during the Program.

 

Parent/Legal Guardian Certification

I certify that I have read, understand, and discussed the above expectations with my Non-Student Minor.

ARIZONA BOARD OF REGENTS
FOR AND ON BEHALF OF NORTHERN ARIZONA UNIVERSITY
Contracts, Purchasing and Risk Management NON-STUDENT MINOR IMAGE RELEASE
UBMS Summer Program (“PROGRAM”)
928-523-4557

 

THIS DOCUMENT HAS LEGAL CONSEQUENCES. IT MUST BE COMPLETED AND SIGNED PRIOR TO PARTICIPATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.

If not defined within the form, all capitalized words shall have the meaning as set forth in the Northern Arizona University Supervision of Non-Student Minors Policy.

 

I am the parent or legal guardian of {main_name} (Non-Student Minor).
On behalf of the Non-Student Minor, I grant permission to the Arizona Board of Regents, for and on behalf of Northern Arizona University and its agents or employees, to make and/or use photographs, videos, or digitally recorded images (Images) taken of the Non-Student Minor while participating in the above named Program, for use in Northern Arizona University publications such as recruiting brochures, newsletters, and magazines, and to use such Images on display boards, or electronic versions of the same publications, or on Northern Arizona University websites or other electronic forms or media, and to offer them for use or distribution in other nonNorthern Arizona University publications, electronic or otherwise, without notifying me.

I waive any right to inspect or approve the finished Images or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known or unknown to me, and I waive any right to royalties or other compensation arising from or related to the use of the Images.

I agree to release and hold harmless the Arizona Board of Regents, on behalf of Northern Arizona University and its agents or employees, and any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages, or liability arising from or related to the use of the images, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication or distribution.

ARIZONA BOARD OF REGENTS FOR AND ON BEHALF OF NORTHERN ARIZONA UNIVERSITY ASSUMPTION OF RISK, WAIVER, AND RELEASE FOR PARTICIPATION IN VOLUNTARY PROGRAMS

THIS DOCUMENT HAS LEGAL CONSEQUENCES. IT MUST BE COMPLETED AND SIGNED PRIOR TO PARTICIPATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.

 

Program (describe and include dates):

Upward Bouind Math & Science

 

Department Contact (name, email, phone):

Chris Wilkens chris.wilkens@nau.edu 928.523.6986

 

Program Location:

Flagstaff mountain campus

In consideration of being allowed to participate in the above-mentioned Northern Arizona University Program, I, {parentlegalGuardian59}, on behalf of myself and my spouse, if any, and our heirs, successors, and assigns:

1. Acknowledge and understand that participation in the Program may involve a variety of activities. Such participation, particularly in field trips, “wilderness trips”, and similar events, may involve risks, including but not limited to, serious personal injury, partial or permanent disability, sickness, disease or illness, property damage, and/or death. These risks may result from my own actions or inactions, from the actions or inactions of others, or may be inherent to participating in the Program. If the Program is an on-line activity, risks include but are not limited to, data mining, phishing, viruses, malware, data breach of on-line information, cyberbullying, exploitation, cyber stalking, online grooming, cyber predators, and image replication. Knowing these risks may occur in an on-line Program, I choose to participate in the on-line Program. I also understand that Northern Arizona University is not an agent of and has no responsibility for any third party that may provide any services during the Program, including but not limited to, food, lodging, travel, and equipment associated with the Program. I understand that I am responsible for ensuring that I am properly prepared for all Program activities, and I represent that I am in good health and am able to participate fully in all Program activities.

2. I acknowledge that Northern Arizona University has taken enhanced health and safety measures, in accordance with guidelines from the U.S. Centers for Disease Control and Prevention, in response to the COVID-19 pandemic. An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. By participating in the Program, I voluntarily assume all risks related to exposure to COVID-19.

3. Assume all the foregoing risks and accept personal and financial responsibility for all damages for personal injury, partial or permanent disability, property damage, or death, caused by me, to the fullest extent allowed by law.

4. Agree not to sue and to waive, release and indemnify the State of Arizona, the Arizona Board of Regents, Northern Arizona University, their boards, universities, officers, employees, agents, and assigns, for any and all claims, damages, personal injury, partial or permanent disability, sickness, disease or illness, property damage, or death, caused or alleged to be caused in whole or in part arising out of or in connection with my participation in, or travel to and from the Program. I understand that my participation in this Program is voluntary.

5. Grant to Northern Arizona University and to its employees, agents and assigns the right to photograph/video me and use the photograph/video and or other digital reproduction of me or other reproduction of my physical likeness for publication processes for use in connection with Northern Arizona University Programs, whether electronic, print, digital or via the Internet.

6. Understand that medical care facilities may not be immediately available, and I accept the increased risk that may pose in the event of injury.

7. Understand that Northern Arizona University does not have medical personnel available at the Program location, and I agree that any medical costs, including emergency medical treatment that may be incurred as a result of my participation in the Program will be my financial responsibility.

8. Hereby consent to Northern Arizona University, any appropriate medical facility, and/or to the physician(s) listed below, providing whatever medical services they may deem necessary in the event of an emergency. I certify that I have adequate insurance and/or other means to pay for any costs and expenses related to these services and I agree to bear such costs and expenses in full.

9. Agree that I will comply with Northern Arizona University’s rules, standards, and instructions for behavior, including the Student Code of Conduct, if applicable, as well as any specific standards of conduct of the Program that may be provided to me. The Student Code of Conduct can be found at: https://nau.edu/university-policy-library/student-code-of-conduct/. I understand that I am not permitted to consume alcohol, possess/use weapons, or illegal substances, or engage in sexual activities while participating in the Program. I agree that Northern Arizona University has the right, in its sole discretion, to enforce the standards of conduct described above, and that it may impose sanctions, up to an including expulsion from the Program or from Northern Arizona University, for violating these standards or for any behavior detrimental to or incompatible with the standards of Northern Arizona University or the Program. I understand that Northern Arizona University has the right to make changes to the format and administration of the Program.

10. ACKNOWLEDGE THAT I HAVE READ THE ABOVE ASSUMPTION OF RISK, WAIVER, AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.

IF THE PARTICIPANT IS UNDER AGE 18, THE PARENT OR GUARDIAN OF THE PARTICIPANT MUST SIGN BELOW.

I am the parent or legal guardian of the Participant. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing Northern Arizona University from liability on my and the Participant’s behalf, (b) waiving my and the Participant’s right to sue Northern Arizona University, (c) and assuming all risks of Participant’s participation in this Program, including travel to and from the Program or any events incidental to this Program. I allow the Participant to participate in this Program. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document.