Please print and complete this form, and send it to:
University Human Resource Services
WorkLife Programs
Administration Building, Room 350
Muncie, Indiana 47306

NAME:  (Please Print ) ________________________________

Disclaimer/Release of Liability Statement 

WorkLife Programs, University Human Resource Services (UHRS) provides child and elder care information to employees of Ball State University and currently enrolled students.  This is a legally-binding Release made by the undersigned to Ball State University, WorkLife Programs (UHRS), for access to information on child and/or elder care services.  The university is not a regulatory agency.  It does not endorse, recommend or conduct any screenings as to the quality or competency of the caregivers associated with WorkLife Programs, UHRS.   While every effort is made to ensure the information released is current and accurate, no representations or warranties, expressed or implied, are made by Ball State University, the WorkLife Programs, or UHRS.  It is the client's responsibility to conduct screenings, assess the quality and competency of the care giver(s) and choose the care giver(s) that best meets the family's needs.

I, the undersigned, agree that, in consideration for any child and/or elder care information provided to me, I will assume and take on myself all of the risks and responsibilities in any way associated with my assessment of the quality and competency of the care giver(s) I choose.  Further, I release Ball State University (and its board of directors, officers, employees, and agents) from any and all liability, claims or actions that may arise from injury or harm to myself, my dependent(s) or damage to my property, in connection with the child and/or elder care services selected by me.

I recognize that this Release means I am giving up, among other things, the right to sue Ball State University, its board of directors, officers, employees, or agents for injuries, damage, or losses I or my dependent(s) may incur through the child and/or elder care services I choose.  I also understand this Release binds my heirs, executors, administrators, and assigns, as well as myself and my dependent(s).

I acknowledge I have been given a copy of the WorkLife Programs "Statement of Rights/Responsibility & Complaint Policy" and the "Disclaimer/Release of Liability Statement."  I further attest I have read and understand both documents and agree to adhere to the terms.

This is a release of your rights.  Please read carefully before signing.

Dated this __________day of ______________________, 20_____

Parent/Guardian:______________________________

Phone: ____________________________________

WorkLife Programs Representative:

_____________________________________________________

Date:  _______________________

Rev. 7/2000