VCOM Institutional Policy and Procedure Manual

VCOM Policy and Procedure

Policy #F003

ACADEMIC VISITOR WAIVER FORM In consideration of permission granted to me by the Edward Via College of Osteopathic Medicine (VCOM or College) to participate in the College _________________________ program, I hereby release and hold harmless VCOM, their agents, employees and officers, from all claims, demands, actions, judgments and executions which I, the undersigned, ever had, now have, or may have, or which my heirs, executors, or assigns may have, or claim to have, against VCOM, their successors or assigns, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by, or arising out of, the above described activity. I, the undersigned, understand that I will not be considered and employee of VCOM, and cannot, therefore, be entitled to any salary or other benefits awarded by the College. I also understand that I am not an agent of the College, and must represent myself as an independent agent or employee of the institution to which I am employed. I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. In witness therefore, I have executed this release at the VCOM __________________________ Campus on __________________________.

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Name of Visitor

Signature of Visitor

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Name of Witness

Signature of Witness

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Name of Witness

Signature of Witness

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_______________________________________ Signature of Faculty/Staff Sponsor

Name of Faculty/Staff Sponsor

VCOM Academic Visitor Policy and Procedure

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