ࡱ> g bjbj x jx je  55555III8D<I-ggg,,,,,,,/2,5 E"g  ,55.,### F55,# ,##V*@+яARv* ,,0- +x33+35+g|#dggg,,!ggg-    3ggggggggg Y :   Date Last reviewedNovember 15, 2024Date Last revisedDecember 7, 2018 Please review the information below. If you have any questions, please contact Risk Management & Insurance at riskmgmt@ucalgary.ca. This document is applicable to Distance Education Learners who are Residents of one of the following provinces and who are applying to undertake an Educational Program with a Practicum course(s) in the same province: British Columbia, Ontario, Northwest Territories and Nunavut. NEW STUDENT ACKNOWLEDGEMENT AND ACCEPTANCE OF WORKERS COMPENSATION COVERAGE WARNING: BY SIGNING THIS DOCUMENT YOU WILL WAIVE THE LEGAL RIGHT TO SUE THE GOVERNORS OF THE UNIVERSITY OF CALGARY OR YOUR PRACTICUM SITE(S) FOR INJURIES OCCURRING AT YOUR PRACTICUM SITE(S). PLEASE READ CAREFULLY! TO: THE GOVERNORS OF THE UNIVERSITY OF CALGARY (UNIVERSITY OF CALGARY) NAME OF STUDENT: ______________________________________________ ADDRESS OF STUDENT: ______________________________________________ ______________________________________________ UNIVERSITY OF CALGARY ID #: ______________________________________________ EDUCATIONAL PROGRAM: ______________________________________________ PROVINCE OF PRACTICUM SITE(S): ______________________________________________ I am aware that as a requirement of my Educational Program, I am required to successfully complete practicum courses and that all practicum courses must be completed at Practicum Sites approved by the ݮƵ. I am aware that by participating in these practicum courses I may be exposed to hazards and risks at the Practicum Site(s), which could result in injury, illness, death, damage, loss, expense and other liabilities or consequences. I am aware that the ݮƵ will purchase Workers Compensation insurance coverage to cover me in the event of any injury, work related illness or death sustained by me and arising out of or occurring during the course of the Practicum. I understand that I and my heirs, next of kin, executors, administrators and assigns, will be prevented from claiming against or suing the ݮƵ or the Practicum Site(s) for damages arising from any injury, work related illness or death sustained by me and arising out of or occurring during the course of the Practicum. I understand that my acceptance of Workers Compensation insurance coverage for my practicum courses is a condition of my acceptance into the Educational Program. I understand that I am required to inform Campus Security at the ݮƵ (403-220-5333) within 24 hours of any injury I incur at the Practicum Site(s) and that I am required to report such injury to the appropriate Workers Compensation authority of the Province of Practicum Site(s) within 72 hours. I further understand that my failure to do so may impair or impede my access to Workers Compensation insurance. I have read and understood this Agreement and I agree to accept Workers Compensation insurance coverage during my Practicum courses. In entering into this Agreement, I am not relying upon any oral or written representations or statements made by the ݮƵ other than what is set forth in this Agreement. Signed this ______________ day of _________________________________, 2__________ ______________________________ ________________________________ SIGNATURE OF STUDENT SIGNATURE OF WITNESS (Non Family Member) _______________________________ PRINT NAME OF WITNESS FOR ADMINISTRATIVE USE ONLY: Student has been reported to Payroll for WCB registration. Date: __________________, 2_____       PAGE 2 ()*<MNO ! 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