Release and Agreement to Hold Harmless and Indemnify

TheCaliforniaEducationCodeSection72640requires,inpart,thefollowing:

"All personsmakingthefieldtrips orexcursions shall bedeemedtohavewaivedall claims against theDistrict ortheStateof Californiaforinjury, accident, illness,ordeathoccurringduringorbyreasonofthefieldtriporexcursion.Alladultstakingout-of-statefieldtripsorexcursionsandallparentsorguardiansofstudentstakingout-of-statefieldtripsorexcur-sionsshallsignastatementwaivingsuchclaims."

Completionofthisformisrequiredofparticipantsinallovernightfieldtrips;participantsinallinternationalorout-of-Statesingledayfieldtrips;participantsinallFieldcourses;andparticipantsinallStudyAbroadcourses.Iftheparticipantisunder18yearsofage,thisformmustbecompletedbytheparticipant'slegalguardianorparent.

ThePalomarCommunityCollegeDistricthasgrantedtheindividualnamedbelow(hereinafterreferredtoas"Participant")permissiontoparticipateinthedesignatedtravel-studytour.

RELEASE

InconsiderationofthepermissiongrantedtotheParticipantbythePalomarCommunityCollegeDistrict,I,theundersigned,herebyreleaseanddischargethePalomarCommunityCollegeDistrict(includingtheGoverningBoardmembers,officers,employees,andagents,hereincollectivelyreferredtoasthe"District")fromallliability,asdefinedherein,arisingoutof,orinconnectionwithmy participationintheabovedescribedtravel-studyfieldtriporassignees.Forthepurposeofthisagreement,liabilitymeansallclaims,demands,losses,causesofaction,suitsorjudgmentsofanyandeverykindthatI,myheirs,executors,administratorsorassigneesmayhaveagainsttheDistrict,orthatanyotherpersonorentitymay haveagainst theDistrict, becauseofany death, personalinjury orillness,orbecauseofany loss ordamagetopropertythatoccursduringtheabovedescribedtravel-studyfieldtriporexcursion,andthatresultsfromanycauseotherthannegligenceoftheDistrict.

INDEMNIFICATION

Ifurtheragreetoholdharmless,defendandindemnifytheDistrictfromanyandallliability,asdefinedabove,resultingfrom,orinanymannerarisingoutofanynegligenceonmypartduringtheabovedescribedtravel-studyfieldtriporexcursion,butnottotheextentthatsuchliabilityisduetothenegligenceoftheDistrict.

RULESANDREQUIREMENTS

Ifurtheragreetoacceptalltherulesandrequirementsofthetravel-studyfieldtriporexcursion,observetheprogramschedules,andtofollowtheinstructionsgivenbysupervisorypersonnelandgranttherighttoterminatemyparticipationintheprogramifitisdeterminedthatmyconductisdetrimentaltothebestinterestsofthegroup,inwhicheventreturnhomeshallbeatmypersonalexpense.AnyviolationoftheserulesandregulationsmaybecauseformysuspensionorexpulsionfromtheCollege,subjecttotheapplicationofappropriateDistrictdueprocessproceduresuponreturn.

RESPONSIBILITY

Ifully recognizeandagreethat theDistrict cannot andwill notbeheldresponsibleformy needs orwell-beingwhennot underthedirectsupervisionofCollegesupervisorypersonnelduringinstructionalactivity.

MEDICALCONSENT

Intheeventofanymedicalemergency,Ido donot givepermissiontoDistrictsupervisorypersonnelonthetriptoauthorizeanyx-rayexamination,anesthetic,medical,dentalorsurgicaldiagnosisortreatment,andhospitalcarethatthemaybenecessaryformysafetyandprotection.

(Initialoneofthefollowingstatements)

Iam18yearsofageorolderandIwillbetheParticipant.

IamtheparentorlegalguardianoftheParticipantwhoisunder18yearsofagetowhomtheabovestatementsapplyandforwhosebenefitIamexecutingtheagreement.

IhavereadthecontentsofthisReleaseandAgreementtoHoldHarmlessandIndemnifyformandunderstanditsterms.Iexecuteitvoluntarilyandwithfullknowledgeofitssignificance.

Givelocationoftravel-studytour: Flagstaff, AZ to Dinosaur, COUnited StatesCityStateCountry

/ /

PleasePrint LastNameFirstNameStudentIDNo.(9digit)BirthDate

Please Print Name of Participant’s Parent or LegalGuardian

SignatureofParticipantorParticipant’sParentorLegalGuardianDate

7/22/2010

I:\ShareAll\Forms\FieldTripWaiverRevised:9/16/09

GEOL 195 Field Studies in Geology

Colorado Plateau Region

May 25 - June 1, 2016

Student Information Sheet

Name: ______Palomar ID: ______

Mailing Address:______

Cell Phone: ______

E-mail:______Date of Birth:______

Emergency Contact Information: ______

______

Medical conditions that the instructor needs to know about: ______

Grades

Your grade will be based on your participation, field journal, and final portfolio of completed activities. Students who participate in all course activities will automatically be given a “C”. Students that complete the field journal and turn in final portfolio will be graded based on the content of these two items.

By initialing this box I acknowledge that I have read and understand the student code of conduct as written by Palomar College and stated within the course detail sheet. I agree to adhere to all terms set by the Code of Conduct and by the instructors for the duration on this field course.

Driver/Rider Information:

As a driver, I have a driver’s license and proof of insurance.

Type of vehicle: ______

 Regular passenger car  High clearance 4-wheel drive

I will be driving my own vehicle and will be looking for passengers.

Number of passengers (with gear) I can take: ______

I will be driving my own vehicle and already have passengers.

Name of passenger(s) (must be an enrolled student):

______

______

I already have a ride with another student.

I need a ride and will be looking for someone to ride with.

Camping Information:

I have my own camping supplies and will be using my own materials.

I have my own camping materials and am willing to share.

I have contacted another student and will be sharing their camp materials.