ASSUMPTION OF THE RISK FORM
I agree that as a participant in the (internship/externship/clinical program name or curriculum name) at (name of company or organization) associated with (college name) Community College (the “College”) scheduled for (start date) to (end date), I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to (potential risks of the activities or related to the work environment [very specifically list here the potential risks involved that the student is assuming]).
I understand that in the event of accident or injury, personal judgment may be required by (name of company or organization) or College personnel regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that the College and/or (name of company or organization) personnel may not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition.
I further agree to abide by any and all specific requests by the College and (name of company or organization) for my safety or the safety of others, as well as any and all of the College’s and (name of company or organization)’s rules and policies applicable to all activities related to this program. I understand that the College reserves the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others.
In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of my property which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury, damage to or loss of my property is directly due to the negligence of the College and/or (name of company or organization). I understand that this Assumption of Risk form will remain in affect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with (program coordinator or College administrator), at which time my visits to or participation in the program will cease.
In case an emergency situation arises, please contact (name) at
(phone number).
I
acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting
these personal risks and conditions of my own free will.
I represent that I am 18 years of age or older and legally capable of entering into this agreement.
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If participant is less than 18 years of age, the following section must be completed:
My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this program, and I agree to be responsible for his/her behavior and safety during this event.
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Approved as to form by Rita R. Woltz, System Counsel for the VCCS, on August 1, 2006.
INTERCOLLEGIATE ATHLETIC
ASSUMPTION OF THE RISK FORM
I
agree that as a participant in the _________________ athletic program at
Participation in this athletic program may contribute to, or result in, the loss of, or damage to, personal equipment and accidental injury, illness, or in extreme cases, personal trauma or death. Risks during participation in this program include, but are not limited to, getting hit and/or hurt by teammates and other participants in practices and games, getting cut and bruised, tearing ligaments, breaking bones, and experiencing head injury or trauma.
I understand that in the event of accident or injury personal judgment may be required by program personnel regarding what actions should or must be taken on my behalf. Nevertheless, I acknowledge that the College personnel may not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition.
I further agree to abide by any and all the College’s rules applicable to this athletic program; and, I will take responsibility for abiding by specific requests made of me for my safety, the safety of others, or the welfare of any general interests concerning the athletic program. I understand that the College reserves the right to exclude my participation in this athletic program if at any time my participation or behavior is deemed detrimental to the safety and welfare of others.
Therefore, in consideration for being permitted to participate in this activity on my own initiative, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of, my property which may occur as a result of my participation in this activity or arising out of my participation in this activity, unless any such personal injury, damage to or loss of my property is directly due to the negligence of the College. I understand that this Assumption of Risk form will remain in effect during my participation in this athletic program, unless a specific revocation of this document is filed in writing with the (Athletic Director/other College administrator), at which time my participation in this athletic program will cease.
I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal risks and conditions of my own free will.
In case an emergency situation arises, please contact ____________________ (name) at __________________ (phone number).
_____ I represent that I am 18 years of age or older and legally capable of entering into this agreement.
__________________________ ____________________________
Participant’s signature Date
__________________________
Address
If participant is less than 18 years of age, the following section must be completed:
_____ My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this and subsequent field trips and agree to be responsible for his/her behavior during this trip.
__________________________ __________________________
Child’s name Parent’s or guardian’s signature
__________________________ __________________________
Address Date
Approved as to form by Rita R. Woltz, System Counsel for the VCCS, on August 1, 2006.