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COLUMBIA UNIVERSITY
GRADUATE SCHOOL OF ARTS AND SCIENCES
Student Activity Liability Waiver Form
First Name _____________________ Last Name _____________________ MI ________
Birthday _____ /______ /______ UNI ____________________ Cell Number ______________
Emergency
Contact_____________________________________________________________________
Name Relationship Cell Number
I intend to participate in the activity called ___________________________ (“Activity”) to be
conducted by __________________________ (“Sponsor/Organizer/Club”) on or about _____
/______ /______ (date).
I acknowledge that I must thoroughly read and understand the information contained in this
registration pertaining to the Activity and the possible risks and hazards that might result from
participation in this Activity.
I understand that my participation in the activities of the Club is subject to any rules and
regulations outlined for me by Club officers and/or any other person(s) overseeing the activities.
I acknowledge that any activities in which I engage as a member of the Club are of my own choice
and judgement, and I agree to participate in a safe manner.
In consideration of my participation in Club activities, I further agree to assume all such risks and
expressly release and hold harmless Columbia University, including its Trustees, faculty,
employees, staff, and other agents of and against any and all liability and responsibility for any
claim or cause of action on account of any personal injury, accident, damage, expenses, or other
loss caused, suffered, or incurred by or to any person(s) or entity during, arising out of or in any
way associated, directly or indirectly, with my membership in the Club.
I acknowledge that I have read and understand the above statements and that I am at least
eighteen (18) years old and of legal age to bind myself to this release and waiver, and that signing
this form constitutes a legal signature confirming that I hereby expressly waive all my rights,
claims, causes of action, and the like of any nature whatsoever which I or my heirs or legal
representatives may have against the University or any of the agents and employees in
connection with my participation in such an activity.
Signature ______________________________________________Date____/____/________
535 West 116
th
Street | 107 Low Memorial Library | New York, NY
10027 212-854-8903 | http://gsas.columbia.edu/