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Canadian Conference on Student Leadership 2009

At
York University
Thursday, November 12 to Sunday, November 15, 2009

FULL NAME (First and Last)

EMAIL ADDRESS

PHONE NUMBER

Conference Options: -Choose only ONE

Option #1 – Full PRICE CHOICE


Nov 12 to 15: inclusive of 3 York is U $50.00
nights stay, *all meals, member
seminars, games and activities York is U $60.00
included volunteer

Stay at Founders Residence at Keele Campus.


**Regular fee to register for this conference is $200!!

METHOD OF PAYMENT – Select One

METHOD CHOICE
CASH
CHEQUE (Payable to York is U)

I HEREBY SIGN THAT THE CORRECT AMOUNT OF MONIES REQUIRED FOR MY


CHOICE IS ENCLOSED

________________________ ____________________
Signature Date

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EMERGENCY CONTACT INFORMATION

VOLUNTEER’S FULL NAME (First and Last)

CONTACT’S FULL NAME (First and Last)

CONTACT’S EMAIL ADDRESS

CONTACT’S PHONE NUMBER

VOLUNTEER’S RELATIONSHIP TO CONTACT

********************************************************************************************

Personal Information

Please list any dietary restrictions and/or allergy information:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________

Please list any special needs or requirements:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________

*Once all forms have been processed, Membership Director, Mina will follow up with
further details.

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RELEASE OF LIABILITY, WAIVER OF CLAIMS,
ASSUMPTIONS OF RISKS AND INDEMNITY AGREEMENT

WARNING: BY SIGNING THIS DOCUMENT YOU


WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE

PLEASE READ CAREFULLY

NAME OF PARTICIPANT AND STUDENT ID# (PLEASE PRINT):

FULL ADDRESS AND TELEPHONE NUMBER:

ACTIVITY:

ASSUMPTION OF RISK
I am aware that participating in the CCSL 2009 has some inherent risks including but not
limited to:

1. Lost or stolen property;


2. Bodily injury during activities;
3. Emotional or physical harm by another attendee

I freely accept and fully assume all risks, dangers and hazards and the possibility of personal injury,
death, property damage or other delay or inconvenience resulting from acts or omissions, including
negligence of York University, York is U, volunteers, students, event coordinators, and event
organizers.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMITY AGREEMENT


In consideration of York University, or its faculty, employees, students, or volunteers allowing me
to participate in University sponsored activities or extra curricular sporting, recreational, social or
personal fulfillment activities, I hereby agree as follows:

1. TO WAIVE ANY AND ALL CLAIMS that I have or may have in the future against York
University, York is U and all other parties involved in this event (all of whom are hereinafter
collectively referred to as “Releases”)
2. TO RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or
expense that I may suffer or that I may suffer as a result of my participation in the activity
due to any cause whatsoever INCLUDING NEGLIGENCE, BREACH OF CONTRACT OR
BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING DUTY
OF CARE UNDER THE OCCUPIERS’ LIABILITY ACT, RSO 1990 c o.2 AS
AMENDED ON THE PART OF THE RELEASEES.
______ (initial here if you have read all the above)

3. TO HOLD HARMLESS AND INDEMNITY THE RELEASEES from any and all liability
for any damage to the property of or to any third party, resulting from my participation in
this event and
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4. This agreement shall be effective and binding upon my heirs, next of kin, executors,
administrators, assigns, and representatives in the event of my death or incapacity.

In entering into this Agreement, I am not relying upon any oral or written representations or
statements made by the Releasees as to what is set forth in this Agreement.

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING
THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT
OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE
RELEASEES. I HAVE ALSO READ AND UNDERSTOOD THE RULES AND REGULATIONS
ACCOMPANYING THIS AGREEMENT AS A SEPARATE DOCUMENT.

Signed this ________________ day of ________________, 20______

_____________________________ _____________________________
Signature of Participant Signature of Witness

_____________________________
Signature of Parent or Guardian, if the Participant is under the age of 18 years.

_____________________________
Please PRINT Parent/Guardian name clearly

_____________________________
Relation to Minor

This agreement must be completed in full, signed dates, witnessed and paragraph 2 must be
initialed before the participant can participate in the event.

PHOTO/VIDEO Consent:

I hereby grant permission to York University and its representatives to take photographs or videos of
me and to make recordings of my voice. I further grant to York University and its representatives the right
to reproduce, use, exhibit, display, broadcast and distribute these images and recordings in any media now
known or later developed for promoting, publicizing or explaining York University and its activities and for
administrative, educational or research purposes. Photographs, video images and voice recordings are the
property of York University.

Print Name_____________________________________________________

Signature_____________________________ Date_____________________

I hereby grant permission to York University to use my name with these images and recordings.

Signature_____________________________ Date_____________________

Privacy: Personal information including images and recordings in connection with this form is collected under the authority of The York
University Act, 1965 and will be used for promoting, publicizing or explaining York University and its activities and for administrative,
educational or research purposes. Personal information may be disclosed to outside service providers for processing and production. If
you have any questions about the collection of personal information by York University, please contact: Information and Privacy
Coordinator, York University, Ross N945, 4700 Keele Street, Toronto, ON M3J 1P3, tel. 416-736-2100 Ext. 20359, email
info.privacy@yorku.ca.

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Canadian Conference on
Student Leadership

APPLICATION PACKAGE
DUE DATE:
Friday, November 6
Please drop off the
signed application forms
(ALL FORMS) PLUS Conference FEE
at 172 South Ross front desk anytime
Monday to Friday 9:00am to 4:00pm.

Thank you 
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