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3 Indemnity Form
(To be completed by parent/guardian)

I ____________________________ the parent of the student hereby indemnity PSAI


Engineering Department , its employees and agents against any claims of any nature
whatsoever which may be brought against them by the student
_________________________, or any third party or other person claiming in behalf of the
student arising out of the student’s untoward incidents or injury or loss of or damage to the
student’s property as a result of entering into and remaining on
________________________, whether the claim is based on
______________________________________ negligence or on the negligence of any of its
employees or agents for which they may be liable.

_____________________________________
Parents/Guardian’s Name Signature

__________________________________
Relationship to the Student

Date: ________________________________

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