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Please complete this form and mail it to the Office of the First- Year Experience in the envelope provided in your Orientation confirmation packet or the address below.

Nasim, Wahaz

285 Columbia Avenue, Jersey City, NJ 07307

DB 10: 1159

(404 )-281-6462

RCS 10: nasimw


day trip

(first choice): Camp Sloane YMCA




(second choice): A Sustainable Adventure: From Cradle to Cradle

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Male / Female



Assumption and release agreement As the person named above, I acknowledge and fully understand that there may be risks inherent in or

associated with my participation in the Navigating Rensselaer & Beyond ("NRBn) activities. I understand that

these activities may involve risk, including losses which may result not only from my own actions, inactions or

negligence, but also from the actions, inactions or negligence of others, the conditions of the facilities, equipment

or areas where the activities are being conducted and/or the rules of the activities. Knowing and understanding the risks involved with my participation in the NRB activities, I hereby assume any and all risk of bodily and

personal injury, death, and damage to personal property, whether known or unknown, inherent in or associated

with participating in these activities.

I hereby release and discharge Rensselaer Polytechnic Institute from all liability in connection with my

participation in the NRB activities except such loss or damage caused by the sole negligence

misconduct of Rensselaer Polytechnic Institute, its officers, trustees, students, agents and/or employees.

or willful

Photo/video services I hereby give RENSSELAER


INSTITUTE, its legal representatives

and assigns, employees, and

those acting with permission of Rensselaer Polytechnic Institute or employees, the right and permission to use,

reuse and/or broadcast and republish still photographs, motion pictures, digital media, videotapes and/or

associated or independent audio or video recordings of me, or reproductions

made through any media, for any purpose whatsoever, including the use of any printed matter in conjunction


thereof in color, or black and white



hereby waive any right to inspect or approve the finished still photographs, motion pictures, digital media ,

videotapes and/or associated or independent audio or video recordings or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that it might be applied.

I hereby release, discharge and agree to save harmless Rensselaer Polytechnic Institute, its representatives ,

assigns , employees or any person or persons, corporation or corporations, acting under its permission or authority , or any person , persons, corporation or corporations , for whom it might be acting, including any firm publishing and/or distributing the finished product , in whole or in part, from and against any liability as a result of any distortion , blurring or alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in the taking , processing , or reproduction of the finished product , its publication, distribution, or broadcast.

Medical release

IIWe give permission for the administration of any and all medical and dental treatment for our son/daughter for the duration of the Navigating Rensselaer & Beyond program. Financial coverage for medical care is subject to Rensselaer s student plan limitations. In the event of serious physical or mental illness, I hereby consent to the notification of the person listed hereon as emergency contact.

I have read and agree to the above statements/As the legal guardian of this student, I join in and agree to be bound by the above statements:

Student signature:


Parent/guardian signature:

(if under 18)


Please return using the pre-addressed envelope from your SO confirmation packet, or mail to:

Office of the First-Year Experience ATTN: NRB confirmation Rensselaer Polytechnic Institute 4226 Academy Hall 11 0 8th Street Troy, NY 12180 USA