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WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT SU Teacher - For Your Records
I have elected to voluntarily participate in the following camp/program at Southwestern University: SU Splash 2012 is a Southwestern University student group program. SU Splash 2012 offers enrichment courses to 9th-12th grade students. This program is designed to give students a chance to take short courses in a wide variety of topics that are designed and led by Southwestern University students. The program includes check-in and registration along with up to 4 hours of classes. Lunch (meals) will be provided. Some classes may involve athletic activity, the use of craft/construction tools or involve a field trip. Student participation may be recorded on digital or film photography, videotape, audiotape, or any other medium. Students may only attend classes for which they are registered to attend. Class participants are expected to stay together as a group during this program. Parents may not attend classes. The event will be held on February 18, 2012 at Southwestern University. ELECTIVE PARTICIPATION: I acknowledge that my participation is elective. RULES AND REQUIREMENTS: I agree to conduct myself in accordance with the rules and requirements of this program or event. INFORMED CONSENT: I have been informed of and I understand the various aspects of this camp, including the dangers, hazards, and risks inherent in camp activities. I understand I could sustain serious injuries, including death as a result of my participation in this program. This could result from actions, inactions, negligence or fault of Southwestern University or others, condition of equipment used, facility conditions, weather conditions, or negligent first aid operations or procedures. I further understand and agree that any injury, illness, property damage, disability, or death that I may sustain by any means is my sole responsibility. RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Southwestern University, including its governing board, directors, officers, employees, agents, volunteers, students for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys fees), arising from any injury to myself or others, property damage or death that may occur as a result of my proceeding with this program. I further agree that Southwestern University and the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts. ASSUMPTION OF RISK: I understand that there are inherent risks and dangers associated with participating in camp and program activities and that there are dangers that cannot be fully foreseen. Specifically, the risk of injury while participating in events and activities related to this program that may include, but are not limited to, athletic activities, swimming and other recreational activities, along with campus based workshops, class field trips and dining services (responsibility of the participant).

Page 2 INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys fees), arising from any injury to myself or others, property damage or death that may occur as a result of my proceeding with this camp. PHOTO RELEASE: I hereby authorize Southwestern University (SU SPLASH 2012 student program) and the non-profit organization Learning Unlimited (LU) to publish photographs, video (digital media) taken of me, and my name, for use in Southwestern Universitys or SU SLASH 2012 student program printed publications and website. I acknowledge that since my participation in publications and websites produced by Southwestern University (SU SPLASH 2012 student program) and LU are voluntary, I will receive no financial compensation. I further agree that my participation in any publication and website produced by Southwestern University (SU SPLASH 2012) and LU confers upon me no rights of ownership whatsoever. I release Southwestern University, its contractors, representatives and its employees from liability for any claims by me or any third party in connection with my participation. PERSONAL MEDICAL INSURANCE: I agree that I have and am currently covered by personal medical health insurance and that I am responsible for any and all medical expenses, health services that I may require as a result of proceeding with this camp program. SEVERABILITY: If any term or provision of this agreement shall be held illegal, unenforceable or in conflict with any law governing this agreement, the validity of the remaining portions shall not be affected thereby. I have read and fully understand the terms of this waiver and release of liability. I understand I have given up substantial rights by signing this agreement, and sign it freely and voluntarily. By my signature, I represent that I am at least eighteen (18) years of age or, if not, that I have secured the signature of my parent of legal guardian as well as my own.

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WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT For Our Records
PHOTO RELEASE: I hereby authorize Southwestern University (SU SPLASH 2012 student program) and the non-profit organization Learning Unlimited (LU) to publish photographs, video (digital media) taken of me, and my name, for use in Southwestern Universitys or SU SLASH 2012 student program printed publications and website. I acknowledge that since my participation in publications and websites produced by Southwestern University (SU SPLASH 2012 student program) and LU are voluntary, I will receive no financial compensation. I further agree that my participation in any publication and website produced by Southwestern University (SU SPLASH 2012) and LU confers upon me no rights of ownership whatsoever. I release Southwestern University, its contractors, representatives and its employees from liability for any claims by me or any third party in connection with my participation. Signature of Participant (Parent/Guardian) : ________________________________ PERSONAL MEDICAL INSURANCE: I agree that I have and am currently covered by personal medical health insurance and that I am responsible for any and all medical expenses, health services that I may require as a result of proceeding with this camp program. SEVERABILITY: If any term or provision of this agreement shall be held illegal, unenforceable or in conflict with any law governing this agreement, the validity of the remaining portions shall not be affected thereby. I have read and fully understand the terms of this waiver and release of liability. I understand I have given up substantial rights by signing this agreement, and sign it freely and voluntarily. By my signature, I represent that I am at least eighteen (18) years of age or, if not, that I have secured the signature of my parent of legal guardian as well as my own. __________________________________ Signature of Participant Date: __________________

I have read and fully understand the terms of this waiver and release of liability. I certify that I have custody of Participant or am the legal guardian of Participant by court order. I join with Participant in granting a release to Releasees as set forth in detail above. ___________________________________ Signature of Parent/Guardian (if applicable) Print Name of Student Participant(s): Date: __________________

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Address: _______________________________________________________________

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Youth Interaction Policy Annual Sign-Off Form


In an on going effort to insure a safe youth camp/program environment, Southwestern University has implemented a Youth Interaction Safety Policy. The policy includes the interaction guidelines listed below. All employees are required to review the entire youth interaction policy on an annual basis. In addition, please read, initial and sign these guidelines in the appropriate sections. Departments are responsible to collect and file these sign-off forms on an annual basis. PART A: (to be completed by all camp coaches, trainers and counselors) COUNSELOR/STAFF PRECAUTIONS All counselors are required to read and initial the following: _____ Always be in view of others _____ Never be alone with a single camper/youth; supervise in pairs whenever possible _____ All physical contact should be appropriate (i.e. high fives, bones). Inappropriate contact such as chest bumps, hugs, kisses, butt slaps or sitting on laps is prohibited. _____ Respect the privacy of campers/youths _____ Use discretion on what you share with campers (i.e. opinions, inappropriate comments, etc.) _____ Use of alcohol, drugs or tobacco products is prohibited _____ No informal communication with campers after the conclusion of camp _____ All campers/youths must have adult supervision until released to a parent or guardian _____ No campers/youths are to be transported in personal vehicles _____ A camper requiring medical attention is to be directed to the athletic trainer or the Director I have read and understand the entire SU Youth Interaction Policy and these guidelines. _____________________________________________
SIGNATURE

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PRINT NAME

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DATE

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Southwestern University Applicant Release
for Employment Purposes) (Disclosure of Use for Consumer Reports

SECTION 604(a) OF THE FAIR CREDIT REPORTING ACT, 15 U.S.C. 1681b(a), ENUMERATES THE PERMISSIBLE CIRCUMSTANCES UNDER WHICH A CONSUMER REPORTING AGENCY MAY FURNISH YOUR CONSUMER REPORT TO A THIRD PARTY SUCH AS YOUR EMPLOYER. ONE SUCH PERMISSIBLE PURPOSE, LISTED AT SECTION 604(a)(3)(B), IS THAT ANY CONSUMER REPORTING AGENCY MAY FURNISH A CONSUMER REPORTTO A PERSON WHICH IT HAS REASON TO BELIEVE INTENDS TO USE THE INFORMATION FOR EMPLOYMENT PURPOSES. THEREFORE, IT IS LAWFUL UNDER FEDERAL LAW FOR THIS EMPLOYER TO SEEK AND OBTAIN, FOR EMPLOYMENT PURPOSES, A COPY OF YOUR CONSUMER REPORT FROM A CONSUMER REPORTING AGENCY.
I, ______________________________________________, have read and understand the above notice which Southwestern University provided to me on _____________, which explains that it is permissible under the Fair Credit Reporting Act for that employer to either procure or cause to be procured, from a consumer reporting agency, a copy of my consumer report to be used by that employer for employment purposes. I further understand that the above-mentioned employer will make a request for an investigative report. This investigative consumer report will contain information on my character, reputation, personal characteristics, or mode of living. Pursuant to section 606(a)(1)(B) of the Fair Credit Reporting Act, 15 U.S.C. & 1681d(a)(1) (B), I understand that I have the right to request a complete and accurate description of the nature and scope of the investigation. (Should you make such a request, such description shall be provided within five (5) days of the request.) I hereby authorize Southwestern University and its agent BackGround Information Services, Inc. to procure or cause to be procured a copy of my consumer report and/or investigative consumer report from a consumer reporting agency. This consent authorizes the employer to procure a consumer report and/or an investigative consumer report at any time during my employment for an employment purpose.

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DATE SIGNATURE OF EMPLOYEE OR PROSPECTIVE EMPLOYEE ___________________________________________ SOCIAL SECURITY NUMBER Date of Birth (For Background Purposes Only) __________________________________________ Drivers License Number State __________________________________________

Initial Background Check Only


Current Address: ________________________________________________________________________________________________________________ Previous Addresses (Last 7 years): ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________ Previous Employers/Educational Institutional Addresses and/or Counties Last 7 years: ________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ________________________________________________________________________________________ Any other names I have been known by (including maiden name): ________________________________________________________________________________________________________________

This disclosure further serves as a request that any present or former employer, police department, educational or financial institution or other person having personal knowledge about me to furnish BackGround Information Services, Inc. and its affiliates or representative any and all information in their possession regarding me in connection with my application for employment. A photocopy/facsimile of this authorization may be accepted with the same authority as the original and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request. Educational institutions are authorized to release my Grade Point Average.

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******Southwestern University does not conduct credit reports
Please check here to have a copy of your consumer report sent directly to you by Background Information Services, Inc. at the address listed above. 1-800-235-3954 www.employeescreen.com