I, _______________________________, the undersigned, hereby apply for permission to participate in the activities of Phi Alpha Honor Society and/or the Student Social Work Association, which are registered organizations with Florida International University ("FIU").

        I understand that the above organizations are not operated by FIU.  I also acknowledge and understand that the activities of these organization could result in serious injury to myself or some other person.  For these reasons, and in consideration of FIU granting me permission to participate in the activities of these organizations, I agree to release and indemnity FIU in accordance with the following paragraphs:

        I agree and acknowledge that participation in these organizations is of my own free will.  While I realize that I may participate in certain activities which are designed to promote and enhance the image and reputation of the State of Florida University System, FIU, I acknowledge that I am acting neither as an employee nor agent  of the State of Florida, the Board of Regents, FIU, or any of their respective officers, employees or agents.

        I, FOR MYSELF, MY HEIRS, EXECUTOR, ADMINISTRATORS, AND ASSIGNS AGREE TO RELEASE, WAIVE, DISCHARGE, AND RELINQUISH AND TO INDEMNIFY AND HOLD HARMLESS THE STATE OF FLORIDA, THE BOARD OF REGENTS, FLORIDA INTERNATIONAL UNIVERSITY, THEIR RESPECTIVE OFFICERS, EMPLOYEES, AND AGENTS, FROM AND AGAINST ALL CLAIMS AND CAUSES OF ACTION WHICH MAY ARISE FROM MY PARTICIPATION IN THE ORGANIZATIONS AND THEIR RELATED ACTIVITIES OR FROM PERSONAL UNRELATED ACTIVITIES WHETHER THE SAME SHOULD ARISE BY REASON OF NEGLIGENCE OF ANYONE ORGANIZING OR PARTICIPATING IN THE ORGANIZATIONS OR OTHERWISE, AND AGREE THAT UNDER NO CIRCUMSTANCES WILL I OR ANYONE CLAIMING THROUGH ME, PROSECUTE OR PRESENT ANY CLAIMS FOR PERSONAL OR BODILY INJURY, PROPERTY DAMAGE OR LOSS, OR WRONGFUL DEATH AGAINST THE STATE OF FLORIDA, THE BOARD OF REGENTS, FLORIDA INTERNATIONAL UNIVERSITY, OR THEIR PERSPECTIVE OFFICERS, EMPLOYEES, OR AGENTS.

        I, for myself and any others claiming through me, accept full responsibility for safety and expenses and assume the complete risk of any injury to myself or my property which may arise out of or in the course of my participation in these organizations.

        I acknowledge that I have read this document carefully, understand the terms and requirements, and fully agree to all conditions contained herein

WITNESSES

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                                                                                                    signature                                                        date

_____________________________                                        _____________________________________________
                                                                                                    Name

                                                                                                   ____________________________________________
                                                                                                     Address

                                                                                                    ____________________________________________
                                                                                                    City, State, Zip

** Please print this form & submit along with your SSWA Application. Thank you.

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