One waiver is required for each child attending. Please Read, sign, and return,
UW-Madison Extension Bayfield County Superior Adventures, Summer 2026
Agreement for Assumption of Risk and Consent for Emergency Treatment – Minors
I, _______________________ (print name of Parent/Guardian), desire to allow _____
(print name of minor child) my minor child/ward to participate voluntarily in the programs conducted by the University
of Wisconsin-Madison Division of Extension.
Parent Guardian Signature: _______________________ Date: _________________
I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. I UNDERSTAND
THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT THE WISCONSIN 4-H
PROGRAM LEADER AT TELEPHONE NUMBER 608-262-2391.
ASSUMPTION OF RISKS:
I understand that not all risks can be foreseen and there are some risks which are unpredictable. I understand that
certain inherent risks cannot be eliminated regardless of the care taken to avoid injuries. Some of these involve foodborn
illness or allergens, strenuous exertions of strength using various muscle groups, and exposure to infectious
disease. The specific risks vary from one activity to another, but in each activity the risks range from: 1) minor injuries
such as scratches, bruises, and cuts, to 2) major injuries and illness such as severe cuts, injuries, allergic reactions, or
severe illness, to 3) catastrophic injuries including anaphylaxis, paralysis, and death. I understand that the University of
Wisconsin – Madison Division of Extension has advised me to seek the advice of my child/ward’s physician before
participating in the program. I understand that I have been advised to have health and accident insurance in effect for
my child/ward and that no such coverage is provided for me by the University or the State of Wisconsin. I KNOW,
UNDERSTAND, AND APPRECIATE THE RISKS THAT ARE INHERENT IN THE ABOVE-LISTED PROGRAMS AND ACTIVITIES, I
HEREBY ASSERT THAT MY CHILD/WARD’S PARTICIPATION IS VOLUNTARY AND THAT I KNOWINGLY ASSUME ALL SUCH
RISKS. I FURTHER AGREE TO ASSUME RESPONSIBILITY FOR EXPENSE OF REPAIR OR REPLACEMENT OF UNIVERSITY OF
WISCONSIN PROPERTY THAT IS ATTRIBUTABLE TO MY CHILD’S OR WARD’S NEGLIGENT ACTS OR WILLFUL
MISCONDUCT.
Parent Guardian Signature: _______________________ Date: _________________
HOLD HARMLESS, INDEMNITY AND RELEASE:
In consideration of permission for my child/ward to voluntarily participation in these activities, I, and on behalf of my
spouse, heirs, personal representatives, estate or assigns, agree to hold harmless and release the Board of Regents of
the University of Wisconsin System and its officers, employees, agents and volunteers, from and against any and all
claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury,
or death which may result from my child/ward’s participation in the above-listed program, except where such loss arises
from the Board’s or its officers’, employees’, agents’, or volunteers’ gross negligence of willful misconduct. I understand
that by agreeing to this clause I am releasing claims and giving up substantial rights, including my right to sue.
Furthermore, I, and on behalf of my spouse, heirs, personal representatives, estate or assigns, agree to defend and
indemnify the Board of Regents of the University of Wisconsin System and its officers, employees, agents and volunteers
from and against any and all claims, demands, actions, or causes of action of any sort arising from damage to personal
property, or personal injury, or death where such loss arises from my or my child’s/ward’s negligent acts or willful
misconduct while participating in the above-listed program.
Parent Guardian Signature: _______________________ Date: _________________
CONSENT FOR EMERGENCY TREATMENT:
I authorize the University of Wisconsin – Madison Division of Extension and its designated representatives to consent,
on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed
physician to my child/ward. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY
HOSPITALIZATION OR TREATMENT REQUIRED PURSUANT TO THIS AUTHORIZATION.
Parent Guardian Signature: ______________________ Date: _________________
Final April 24, 2023 (reviewed by UW Madison Risk Management, Office of Legal Affairs, Extension Policy Advisor)