UC Night Arizona

Student Contact Information

First Name

Lived First Name (if different)

Middle Name

Last Name

Birthdate

Email Address

Mailing Address

Country

Street

City

Region

Postal Code

Current or Last Attended School Name
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I will apply as a:

I plan on entering the UC system in:

Would you like a parent/guardian to receive information about the event?

Yes

No

Parent/Guardian FIRST Name

Parent/Guardian LAST Name

Parent/Guardian Email address

Would you like to share your contact information with the other UCs participating in this event?

Yes

No

Optional Information

Major of Interest

Alternate Major of Interest (if applicable)

Discipline of Interest

Ethnicity (Select all that apply)
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Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In return for being permitted to participate in the following activity or program (“The Activity”), including any associated use of the premises, facilities, staff, equipment, transportation, and services of the University, I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue The Regents of the University of California, its directors, officers, employees, and agents (“The University”), from liability from any and all claims, including the negligence of The University, resulting in personal injury (including death), accidents or illnesses, and property loss, in connection with my participation in the Activity and any use of University premises and facilities.

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injury. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains, to 2) major injuries such as eye injury, joint or bone injuries, heart attacks, and concussions, to 3) catastrophic injuries such as paralysis and death.

Indemnification and Hold Harmless: I also agree to indemnify and hold The University harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of my involvement in The Activity, and to reimburse it for any such expenses incurred.

Severability: I further agree that this Waiver of Liability, Assumption of Risk, and Indemnity Agreement is intended to be as broad and inclusive as permitted by law, and that if any portion is held invalid the remaining portions will continue to have full legal force and effect.

Governing Law and Jurisdiction: This Agreement shall be governed by the laws of the State of California, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the Courts of the State of California.

Acknowledgment of Understanding: I have read this Waiver of Liability, Assumption of Risk, and Indemnity Agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I confirm that I am signing the agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Acknowledgment

I acknowledge and agree to sign the above document

Your parent or guardian is also required to read, acknowledge, and sign the UCI Waiver of Liability on your behalf. We will send them a copy of the form directly to sign via email.

I understand that my parent or guardian must read, acknowledge and sign the UCI Waiver of Liability on my behalf.

Guest Information

Will you be bringing a guest?
*Due to space there is a 1 guest limit. Guests must be a parent, guardian or family member over 25

Please provide the name (first and last) & relationship to the student

Guest Name #1

Guest Email