TBRHRI waiver

“Waiver of Claims” and “Release of Liability” Form

NOTE:  Please read carefully before signing; activity waivers have held up in Canadian courts.
Consider that you are assuming both physical and legal risks which have potential financial
implications for yourself and/or your family should you be injured or killed wh ile participating in
Thunder Bay Regional Health Research Institute Activities.

The Thunder Bay Regional Health Research Institute (TBRHRI) promotes, conducts, permits or otherwise
engages in international student programs, visiting scientist programs, career development
programs, research projects and other similar or related arrangements. Given the diverse nature
and various locations at which such Programs may be undertaken, individuals must acknowledge
that participation in such Programs may expose them to various risks of damage to property, or
physical injury, sickness or death.


I, _________________________________(please print name),  hereby release TBRHRI, its
agents, volunteers and employees from all liabilities, claims, demands, actions and causes of
action of any nature whatsoever arising from, or related to, any damage of any nature
whatsoever, including but not limited to: damage, loss, theft, or destruction of property or any
injury, including death, that I may sustain, to whatever extent arising from, but notwithstanding
that such damage, theft or destruction of property, injury, death or result from the negligence of
TBRHRI, its agents, volunteers or employees while attending, participating in or traveling to and
from said activities.

I further state and affirm that I am in proper physical condition and health to participate in such
activities. I also state and affirm that I am aware and agree that this release shall be binding
upon my heirs, estate trustee, successors and assigns.

I have read and understood this Agreement prior to signing it, and am aware that by signing this
Agreement I am waiving certain legal rights which I or my heirs, executors, administrators,
successors and assigns may otherwise have or have had against TBRHRI. I do further
acknowledge that it has been recommended to me that I seek independent legal advice prior to
executing this Agreement and I declare that I have either received such advice or have declined
to seek such advice. I further declare that I have attained the age of 18 years.

Signed: The ____________ day of _______________________, of the year ________________

Signature: _______________________________________ Date: _______________________

Parent/Guardian Signature____________________________ Date:_______________________

Witnessed by: ____________________________________ Date: _______________________

Names & telephone number of two people to contact in case of an emergency: