Uvic Unity - contract

The personal information contained within this document will be kept strictly confidential. Only the event’s supervisory team will have access, except in the case of an emergency.

For an electronic version of this form, please email: Uvic.Unity@gmail.com

Please keep a copy of all documents for your own records.

Student Information:

Participant Name: ________________________________________

Birthdate (d/m/y): __ / __ / ____ Age as of May 30^th, 2007: ___

Grade: ____ High School: ___________________________________________

Presentations:

The preliminary topic for my personal presentation is: _________________________________________

It will be approximately: 5 / 10 / 15 minutes.

I will probably require: powerpoint software / TV, VCR & DVD / photocopying / a sasquatch / other: ___________________________

Emergency contacts:

Name: ________________________________________

Relation: _________________________ Phone number(s): ( ) ____ -_____ ( ) ____ -_____

Name: ________________________________________

Relation: _________________________ Phone number(s): ( ) ____ -_____ ( ) ____ -_____

Special Requirements:

I have the following special need(s) (dietary, medical, accomodation, and/or other):

I have attached further documentation regarding this need: Yes / No # Pages: __

UVic Unity is committed to accommodating these needs whenever possible; the earlier the request is received, the more likely we will be able to accommodate you. Be sure to contact UVic Unity by email (Uvic.Unity@gmail.com) or telephone (250-472-4393) to confirm.

Personal Removal or Dismissal:

In the event of a problem, I would use the following means to transport myself home:

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But, of course, that’s not going to happen!

Fee & Security Deposit:

I have: __ mailed this form with two separate cheques / money orders (please indicate which), one each for the $15 attendance fee & $50 security deposit, and would like a receipt sent to me.

Address cheques or money orders to UVIC PRIDE (not Uvic Unity). Mail to: UVic Pride Collective / Student Union Building / University of Victoria/ P.O. Box 3035 / Victoria, B.C. V8W 3P3

Note: security deposit will only be cashed if there is a problem at the event (need for student dismissal, damage to property, etc). Otherwise, we tear it up. If you have a problem providing this deposit, please talk to our event coordinator (Kelley Logue).

__ dropped off this form with two cheques / money orders (please indicate which) included.

Please drop this off at the UVSS General Office, in the Student Union Building (SUB), room B128, open 9:00-4:30 on regular academic weekdays. Address your sealed envelope to UVic Unity, and ensure a UVSS staff member signs across the seal of the envelope before you depart. Contact 472-4317 or alma@uvic.ca to confirm the office is open.

__ spoken with the Uvic Unity facilitator (Kelley Logue) regarding this.

It is not recommended that you mail cash. Though we will accept this method of payment, we do not assume any responsibility for envelopes mailed or dropped off containing cash. A money order (from the post office) or cheque is far more secure.

I have read and agree to follow all the rules and guidelines stated within the Uvic Unity Policy for Student Participants; I will additionally use my own common sense to determine proper conduct for myself and my fellow students if a situation should arise not covered within this policy.

Signed,

_________________________________ ________________________________

Attendee Signature Guardian Signature

(if attendee is under 19)

Release of Liability

I, and my heirs, in consideration of my participation in the UVic Unity workshop retreat, from May 31^st to June 3^rd, at the University of Victoria campus, hereby release Uvic Pride, the UVic Student Transition Centre, Uvic Counseling Services, the Board of Regents of the University of Victoria, its officers, employees and agents, and any other people officially connected with this event, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating in this event. Specifically, I release said persons from any liability or responsibility for my physical condition, for the condition or selection of campus locations, and for the presence or actions of any other participants. I am aware of the risks of participation, which include, but are not limited to, the possibility of sprained muscles and ligaments, broken bones, and fatigue. I hereby state that I am in sufficient physical condition to accept a moderate level of physical activity, and will refrain from participating in any activity I do not feel comfortable with or physically capable of. I understand that participation in this program is strictly voluntary and I freely chose to participate. I understand that the University does not provide medical coverage for me. I verify that I will be responsible for any medical costs (not otherwise covered by BC medical) that I incur as a result of my participation.