DAY TRIP CONFIRMATION

/ SIGNATURE

PAGE

Please complete this form and mail it to the Office of the First- Year Experience in the envelope provided in your Orientation confirmation packet or the address below.

Nasim, Wahaz
285 Columbia (404 )-281-6462 Wednesday Wednesday day trip (first choice): day trip (second Camp Sloane YMCA A Sustainable Adventure: From Cradle to Cradle Avenue, Jersey City, NJ 07307 DB 10: 1159 RCS 10: nasimw

choice):

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RELEASE INFORMATION
Assumption and release agreement As the person named above, I acknowledge associated negligence, with my participation these activities may involve risk, including and fully understand Rensselaer that there may be risks inherent in or that or equipment inactions

in the Navigating

& Beyond ("NRBn) activities.

of others, the conditions

I understand

losses which may result not only from my own actions, or negligence

but also from the actions, inactions

of the facilities,

or areas where the activities are being conducted and/or the rules of the activities. Knowing and understanding the risks involved with my participation in the NRB activities, I hereby assume any and all risk of bodily and personal injury, death, and damage in these activities. Rensselaer Polytechnic Institute from all liability in connection caused by the sole negligence students, with my or willful to personal property, whether known or unknown, inherent in or associated with participating

I hereby release and discharge participation misconduct in the NRB activities of Rensselaer

except such loss or damage

Polytechnic

Institute, its officers, trustees,

agents and/or employees.

Photo/video services I hereby give RENSSELAER those acting with permission

POLYTECHNIC of Rensselaer

INSTITUTE, Polytechnic

its legal representatives

and assigns,

employees,

and

Institute or employees,

the right and permission

to use,

reuse and/or broadcast and republish still photographs, motion pictures, digital media, videotapes and/or associated or independent audio or video recordings of me, or reproductions thereof in color, or black and white made through therewith. any media, for any purpose whatsoever, including the use of any printed matter in conjunction

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I hereby waive any right to inspect or approve the finished still photographs, motion pictures, digital media, videotapes and/or associated or independent audio or video recordings or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that it might be applied. I hereby release, discharge and agree to save harmless Rensselaer Polytechnic Institute, its representatives, assigns, employees or any person or persons, corporation or corporations, acting under its permission or authority, or any person, persons, corporation or corporations, for whom it might be acting, including any firm publishing and/or distributing the finished product, in whole or in part, from and against any liability as a result of any distortion, blurring or alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in the taking, processing, or reproduction of the finished product, its publication, distribution, or broadcast.
Medical release

IIWe give permission for the administration of any and all medical and dental treatment for our son/daughter for the duration of the Navigating Rensselaer & Beyond program. Financial coverage for medical care is subject to Rensselaer s student plan limitations. In the event of serious physical or mental illness, I hereby consent to the notification of the person listed hereon as emergency contact. I have read and agree to the above statements/As the legal guardian of this student, I join in and agree to be bound by the above statements: Student signature: Date: Parent/guardian signature: (if under 18) Date:

Please return using the pre-addressed envelope from your SO confirmation packet, or mail to: Office of the First-Year Experience ATTN: NRB confirmation Rensselaer Polytechnic Institute 4226 Academy Hall 110 8th Street Troy, NY 12180 USA

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