THE UNIVERSITY OF WESTERN ONTARIO

École de langue française de Trois-Pistoles

ACKNOWLEDGEMENT AND ASSUMPTION OF RISK

NAME OF PARTICIPANT: _____________________________________________________________________

I am aware that during field trips, exchanges or other excursions in which I am participating in under the arrangements of The University of Western Ontario at

L’ÉCOLE DE LANGUE FRANÇAISE DE TROIS-PISTOLES certain risks and dangers may occur, including but not limited to, the hazards of travelling,

accidents or illness in remote places without medical facilities, the forces of nature and travel by air, water, train, automobile or other means as well as exposure to customs

and practices of societies different from our own. Accordingly, I understand that despite its efforts, the University may not be able to ensure my complete safety at all times

from such risks and dangers.

More particularly, I appreciate The University of Western Ontario does not carry accident or injury insurance for my benefit and also that there may be certain matters

for which I could be held at fault personally if the accompanying circumstances do not relate to or arise from my education or if my activities or conduct fall short of what would be considered

a reasonable standard for an individual in my position. In these cases I agree to be accountable in all respects for my own actions and not to ask the University or its employees to accept the consequences thereof;

further, I agree to be responsible for any claims made against the University in relation to such actions.

I acknowledge that I have been advised by The University of Western Ontario of such risks and dangers as well as the need to act in a responsible manner at all times.

My signature below is given freely in order to indicate my understanding and acceptance of these realities and in consideration for being permitted by the University

to participate in the above mentioned Programme.

Dated: ______________________ Signature: _______________________________

Your Health Card Number: _______________________________________________________

Other Health Insurance Plan, Type and Number: _____________________________________

Person to Contact in Case of an Emergency: ________________________________________

Telephone Number: ___________________________________________________________