Excursion Liability Release And Agreement printable pdf download

MIRACOSTA COMMUNITY COLLEGE DISTRICT

EXCURSION LIABILITY RELEASE and AGREEMENT

__________________________________________________

___________________________________ __________

Printed Name of Faculty/Staff Member Supervising Excursion

Signature of Faculty/Staff Member

Date

__________________________________________________

___________________________________ __________

Printed Name Vice President, Dean or Designee

Signature Vice President, Dean or Designee Date

Completion of this form is required for participation by students/non-employees over the age of 18 in any and all one day, in-state, off-

campus excursions (i.e., field trips, club activities, or any other special event) sponsored by the MiraCosta Community College District.

Please submit Form B-169M for participants under the age of 18. No one will be permitted to attend/participate in any excursion specified

below unless this form has been completed, approved, and signed by the participant and faculty/staff member supervising/coordinating

the excursion and Vice President, Student Services or Instructional Dean no later than the day of the excursion. Instructional off-campus

meetings need to be announced in the course syllabus (please attach to form). A signed, fully completed form is to be forwarded to the

Office of the Director/Risk Management, MS #14.

The MiraCosta Community College District ("District") grants:

The Participant(s), who have read the information below and who have signed the reverse side of this form, have permission to participate

in the excursions specified below:

______________________________________________________________scheduled for (date)___________________

In consideration of the permission granted by the District for participation to participate in the excursion named above, the undersigned,

understand and agree as follows:

Release and Discharge

As a condition of my participation in these excursions, I understand that California Education Code Section 35330(d), provides that “all

persons making the field trip or excursion shall be deemed to have waived all claims against the District or the State of California for

injury, accident, illness or death occurring during or by reason of a field trip or excursion. All adults taking out-of-state field trips or

excursions and all parents or guardians of students taking out-of-state field trips or excursions shall sign a statement waiving such

claims”. Participant agrees to release and discharge (agreeing to make no claim and not to sue) the State of California or the District (its’

Board of Trustees, officials, employees, agents) (“Released Parties”) from all claims of injury or loss which the participant or the minor

participant for whom parent or legal guardian signs for, may suffer, arising in whole or in part from the Participant’s enrollment or

participation in the excursion, including but not limited to any injury, accident, illness, or death or any loss or damage to personal property

occurring during or by reason of the participation in said excursion.

Rules and Requirements

Obey and uphold any and all rules and requirements of the excursion; observe the designated schedule and follow the instructions given

by District supervisory personnel in all matters pertaining to the excursion.

I grant the District, acting by and through the personnel designated to supervise said excursion, the right to terminate my participation in

the excursion if it is determined by them that my continued participation is detrimental to or in conflict with the purpose of the excursion, or

is not in harmony with the best interests of the other participants and/or supervisory personnel.

Violation of any of the stated rules or regulations pertaining to this excursion will result in my immediate removal from said excursion.

Medical Consent

In a medical emergency arising during the course of the excursion, I grant to the District acting through its designated supervisory

personnel full authority to take any action deemed necessary to protect my health and safety at my expense, including, but not limited to,

placing me under the care of a doctor, hospital and/or other qualified medical personnel to examine and/or treat.

Accident/Emergency Illness

Student Accident Insurance does not cover field trips outside of the US. Coverage applies while; (a) attending regularly scheduled classes

at the District; (b) while attending college-sponsored activities, including club activities, or;

Drug and Alcohol Statement

Use, possession, sale, distribution, or manufacture of, or the attempted sale, distribution, or manufacture of alcohol and drugs, including

controlled substances, on District properties or at official sponsored District functions is unlawful or otherwise prohibited by District Board

of Trustees Policies 3550 & 3560.

I hereby authorize the individuals listed on the reverse side of this form to participate in this excursion with the terms and conditions

described above and affirm that I personally observed each individual signing this form.

If the participant is younger than 18 years of age, Form

B-169M

must be completed. Note: Minors may not participate in any international

travel/activity.

Form B-169 Class 09/14/2010

Excursion Liability Release And Agreement

Related Articles

Related forms

Related Categories