RETURN TO CSUN HOMEPAGE

Insurance & Risk Management

ENVIRONMENTAL HEALTH & SAFETY
TEL NO: (818) 677-2079
FAX NO: (818) 677-5853
MAIL DROP: 8284
Guest Lecturer
Informed Consent/ Hold Harmless Form
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This information is provided to (Enter Your Name)
prior to: (Enter name of Service/Activity)
at, or in conjunction with California State University, Northridge. I understand and acknowledge that as a condition precedent to performing the above named Services/Activities, of participating in the above named activity.

1.
I am working as an independent contractor and not as an employee of California State University, Northridge.
2.
I am solely responsible and liable for any and all taxes, cost, interest, assessments, penalties, damages, attorney fees, or other costs which may arise from the performance of these services or activities.
3.
In consideration of my receipt of payment for, and/or my voluntary participation in: (Enter name of Service/Activity)
  , I hereby waive, personally release, hold harmless and forever discharge any and all claims for damages for personal injury, including death, or property damage which I may have, or which may hereafter accrue to me, against the California State University, Northridge as a result of my participation in this event.

This release is intended to discharge the State of California, the Trustees of the California State University, California State University, Northridge and its Auxiliary Organizations; and their officers, agents, employees and volunteers from and against any and all claims arising out of or connected in any way with my participation in the above event/activity, even though that liability may arise out of the negligence of the carelessness on the part of the University or persons mentioned above.
I have read the Hold Harmless Waiver and Release, and understand the terms used in it. I also understand that by signing this document, I may be giving up legal rights which I, or others claiming through me may have now or in the future. It is further understood that accidents and injuries can arise out of this activity; knowing those risks exist, nevertheless, I hereby agree to assume those risks and to release and to hold harmless all persons or agencies mentioned above who (through negligence or carelessness) might otherwise be liable to me (or my heirs or assigns) for damages. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.
This Hold Harmless Waiver and Release is freely and voluntarily given with the understanding that rights to legal recourse against the State are knowingly given up in return for allowing my participation in the activity or service described above.
~ THIS IS A RELEASE OF YOUR RIGHTS - PLEASE READ CAREFULLY BEFORE SIGNING ~
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Lecturer's Signature: Date:
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