ࡱ> 354g bjbjVV 4r<r<@@ t  giiiiii$\  ggw"S0,   Z?@4( @ `: University of Washington Acknowledgment of Risk and Consent for Treatment for ADULT Field Trip Participants Section 1 (To be completed by field trip leader) Class: Field trip leader: Telephone: Address: Field trip date(s): Equipment/supplies to be provided: by participant: by field trip leader: Immunizations required: Physical activities to be undertaken include: Risks inherent in this field trip include bodily injury due to: Section 2 (To be completed by adult field trip participants) I acknowledge that there are certain risks inherent in field trips, including but not limited to those indicated in Section 1. I acknowledge that all risks cannot be prevented and I assume those risks beyond the control of the University staff. I represent that I am able, with or without accommodation, to participate in this field trip, am able to use the equipment and/or supplies described above, and have obtained the required immunizations. I also agree to assume all risks of personal trips or activities undertaken at my own initiative during travel to and from or during the course of the field trip. Should I require emergency medical treatment as a result of accident or illness arising during the field trip, I consent to such treatment. I acknowledge that the University of Washington does not provide health and accident insurance for field trip participants and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment. I will notify the trip leader in writing if I have medical conditions about which emergency medical personnel should be informed. Signature Date Section 3 (General Information) To request disability accommodations for this field trip, please contact Disabled Student Services at least 10 days in advance of the trip by calling (206)543-8924 (voice): (206)543-8925 (TTY): or (206)616-8379 (FAX). Immunizations may be obtained through the Hall Health Primary Care center (206)685-1011 or your primary care physician. lmvx& ' k |}߻h| h(~CJ h(~CJ h(~CJ h(~ h(~CJ h(~5CJ h(~6CJ h(~CJ h(~>*CJhB! h(~5;CJ h(~;CJlm # ; U  $x]gd(~ h$<gd(~ h$xgd(~ $xgd(~ $xgd(~ $xgd(~ $gd(~xgd(~$a$gd(~xgd(~gd(~ k im|}zy $ & F<a$gd(~xgd(~ &d P gd(~ <Z^Zgd(~ P$xgd(~xgd(~gd(~ x]gd(~&d P ]gd(~ $x]gd(~ $x]gd(~ zgd(~ $ & F(a$gd(~21h:pY/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H (~Normal5$7$8$9DH$_HmH sH tH F@F (~ Heading 2$$@&a$5CJD@D (~ Heading 3$ @&CJDA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List l$@l S-Envelope Address!@ &+D/^@ CJOJQJ^JBOB (~ Page Title $a$5CJ<B@< (~ Body Text $a$CJ@P@"@ (~ Body Text 2 $xa$CJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   z 8@0(  B S  ? Appendix_TwolPPPPPP &&9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType $&33zzC{3J4hh^h`CJOJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(C{3d        |m5puG:&S-Q>K,LTN@\@e gyhk(~^IYpfth 8T'lY^!U}@`@UnknownG* Times New Roman5Symbol3. * Arial?= * Courier New;WingdingsACambria Math"h00!243QHP ?(~2!xx UNIVERSITY OF WASHINGTONTerry Taft HarterRebecca L Bullock 2 Oh+'0  (4 T ` lxUNIVERSITY OF WASHINGTONTerry Taft HarterNormalRebecca L Bullock 22Microsoft Office Word@@.}@.}0՜.+,0 hp  University of Washington UNIVERSITY OF WASHINGTON Title  !"#$%'()*+,-0Root Entry F孝21Table WordDocument4SummaryInformation(DocumentSummaryInformation8&CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qRoot Entry FpQ9@1Table WordDocument4SummaryInformation(  !"#$%876 4<H_AdHocReviewCycleID_NewReviewCycle_EmailSubject _AuthorEmail_AuthorEmailDisplayName 4fBAck of Risk forms - Edited to remove field trip insurance wordingbbullock@u.washington.eduRebecca L. BullockDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q՜.+,D՜.+,\ hp  University of Washington UNIVERSITY OF WASHINGTON Title@H$,