Informed Achnowledgement of and Consent to Trip Hazards and Risks

Informed Acknowledgement of andConsent to Trip Hazards and Risks

CCOC: Activity/Event: Participant Name: HomeAddress: Student ID Number:

Location: Dates Covered: Date of Birth: Phone: Allergies:

InCaseofEmergency,Notify:Name:Phone:

Relationship:

Theundersignedparticipantandhisorherparentsorlegalguardian,ifparticipantisundertheageofeighteen(18),herebyexecutesthisInformedAcknowledgementofRiskforhimself(herself)(themselves),andhis(her)(their)heirs,successors,representativesandassigns,andherebyagreesandrepresentsasfollows:

I understand that, although the College will take steps to foster field trip safety, there are inherent risks in many activities and there are significant levels of personal responsibility that I must assume for myself. Iamawarethatduringmyvoluntaryparticipationintheabovelistedactivity,certaindangersmayoccur,includingbutnot limitedto death,permanentparalysis,injuries,accidents,illness,andthehazardsandforcesofnature,allofwhicharepotentiallyassociatedwithstudentparticipationinthevariousphysicaland/ortravelactivitiesinvolvedwiththis, or any other program related to this, activity/event.

Specifically:

IunderstandthatIamnotpermittedtouse,andIspecificallyagreeanddeclarethatIwillnotuseorpossess,alcoholorillegaldrugsonthisoranyothercollege-sponsoredfieldactivity.IcertifythatIaminexcellenthealthandhavenomedical,physical,oremotionalimpairments,conditionsorconcernsthatmightinhibitmyparticipation,orjeopardizemysafetyorthesafetyofothers,whileparticipating.Iunderstandthatneitherthecollegenoranyofitsagentsorinstructorsservesasguardiansorinsurersof mysafety,andthatthecollegedoesnotprovidespecialinsuranceformyprotection.

Inconsiderationof,andaspartpaymentfor,therighttoparticipateintheseactivitiesandservicesarrangedformebyLowerColumbiaCollege,Ihaveanddoherebyassumealltheabove-describedrisksandanyotherrisksassociated with this field tripor the above-described activity/event.

I certify that I am of lawful age and am competent to sign this Informed Acknowledgement and Consent. I,theundersigned,havereadthisAcknowledgementofandConsenttoTripHazardsandRisksandunderstanditstermsand therisksinvolvedandaccepttheserisks.IunderstandandagreebymysignaturehereonthatIhavehadtheopportunitytodiscussthisdocumentwithanyonethatImightchooseandthatIfreelysignit.IHAVEFULLYINFORMEDMYSELFOFTHECONTENTSOFTHISACKNOWLEDGEMENTBYREADINGITBEFORESIGNING.ICERTIFYUNDERPENALTYOFPERJURYUNDERTHELAWSOFTHESTATEOFWASHINGTONTHATTHEFOREGOINGISTRUEANDCORRECT.

DATED thisdayof

Signatureof StudentSignatureofWitness

SignatureofParentorGuardianifparticipantisundertheageof18

Revised 07/15