Within Our Reach Conference: Waiver Form By signing below, I ________________________________ (parent/guardian) permit _____________________________ (student) to participate and contribute in the "Within Our Reach" conference. I am also aware of and agree to the following: 1. I will not sue, release, and discharge the University of California, Los Angeles (UCLA), the "Within Our Reach" conference, its officers, agents, and employees, from all liability to ____________________(student), his/her representatives, heirs, and the next of kin to or death of the participant or damage of property of above retreat. This agreement, release, waiver, and discharge shall not apply to any personal or property damage sustained by participant arising from the negligent acts of omissions of UCLA and the "Within Our Reach" conference. 2. To indemnify and hold harmless UCLA and the "Within Our Reach" conference from any loss, liability, damage, or costs, that may be incurred due to the acts of omissions of the participant during participation in the above activity or functions. 3. That in the event of an accident or sudden illness, UCLA staff and the "Within Our Reach" conference and its representatives, officers, and agents have my permission to obtain whatever emergency medical treatment may be deemed necessary on the participant. _________________________________ ________________________________ Student’s Last Name First Name _______________________ __________________________ _____________ Address City, State Zip ______________________________________ _____________________ Signature of Parent/Guardian Date ____________________________ _________________________ Home Phone Work Phone