University of Dementlieu
Expression of Interest & Permission
Full Name:
Class/Degree:
In consideration of my application and permitting my participation in this activity:
1. I certify that I am physically fit, have sufficiently prepared for participation in this experience, and have not been advised not to participate by a medical physician or otherwise.
2. I assume all risk and liability associated with my attendance to the field experience and agree to indemnify and hold the University of Dementlieu harmless from any claims, damages, or losses arising from such activities, including but not limited to: liability arising from the fault of the entity recognized, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my travelling to and from this experience. I hereby assume all of the risks of participating in any/all activities associated with this experience.
3. I agree to abide by all rules and regulations established by the University of Dementlieu faculty regarding the chosen activity. Failure to comply may result in termination of this agreement as well as possible legal action depending on the severity of the transgressions.
4. I understand that this field experience is considered as academic work and will be conducted as such.
YOUR SIGNATURE INDICATES THAT YOU HAVE READ AND AGREED TO THE ABOVE. Date:
Signature:
Address to: Medical Sciences Office #08
Dr. Rosalie Épineux, Doctoresse of Medicine, Administrator & Lecturer
University of Dementlieu - Port-à-Lucine - Dementlieu
