Trip Waiver
LYNDON STATE COLLEGE – WAIVER AND RELEASE OF LIABILITY
I hereby release Lyndon State College (LSC), its officers, faculty, agents, employees, successors, and assigns from any and all liability, not caused directly by negligence of LSC or its representatives, arising out of or in any way related to my participation in a student field trip to visit ____________________ from ____ (date) to ___________ (date), 200___.
I understand that there will be activities required of me as necessary for participation in the above-related trip and that there is some risk involved in all such activities. I hereby accept that risk.
I understand that the College is providing supervised _____________(activity) and that ________________ (trip leader), of the ___________ (department), will be accompanying the participants and will be the primary contact.
If I require medical care while participating in the activities of this trip, I authorize LSC through its employees or agents (including the staff of the ___________ department) to contact Dr. _______________ at phone number ______________, or if that is not possible, I authorize LSC through its employees or agents to summon emergency medical care or to take me to the nearest medical facility for the purposes of receiving medical care with the understanding that I will not hold LSC, or its employees, agents or representatives responsible for the actions of the agents, representatives or employees of the medical facility and that I will assume any and all responsibility for payment of same. My medical insurance carrier is ___________________________. The policy number is _______________________.
SIGNATURE
I confirm that I have carefully read this WAIVER AND RELEASE and agree to its terms knowingly and voluntarily. I also confirm that I am the parent or legal guardian of the child or I am a student 18 years or older.
I have signed this WAIVER AND RELEASE this ___ day of ________, 200__.
___________________________________________ _________________
Student's signature (If 18 years or older) Date
__________________________________________ _________________
Signature of Student's Parent or Legal Guardian Date
(If Student is less than 18 years)
August 2014
I hereby release Lyndon State College (LSC), its officers, faculty, agents, employees, successors, and assigns from any and all liability, not caused directly by negligence of LSC or its representatives, arising out of or in any way related to my participation in a student field trip to visit ____________________ from ____ (date) to ___________ (date), 200___.
I understand that there will be activities required of me as necessary for participation in the above-related trip and that there is some risk involved in all such activities. I hereby accept that risk.
I understand that the College is providing supervised _____________(activity) and that ________________ (trip leader), of the ___________ (department), will be accompanying the participants and will be the primary contact.
If I require medical care while participating in the activities of this trip, I authorize LSC through its employees or agents (including the staff of the ___________ department) to contact Dr. _______________ at phone number ______________, or if that is not possible, I authorize LSC through its employees or agents to summon emergency medical care or to take me to the nearest medical facility for the purposes of receiving medical care with the understanding that I will not hold LSC, or its employees, agents or representatives responsible for the actions of the agents, representatives or employees of the medical facility and that I will assume any and all responsibility for payment of same. My medical insurance carrier is ___________________________. The policy number is _______________________.
SIGNATURE
I confirm that I have carefully read this WAIVER AND RELEASE and agree to its terms knowingly and voluntarily. I also confirm that I am the parent or legal guardian of the child or I am a student 18 years or older.
I have signed this WAIVER AND RELEASE this ___ day of ________, 200__.
___________________________________________ _________________
Student's signature (If 18 years or older) Date
__________________________________________ _________________
Signature of Student's Parent or Legal Guardian Date
(If Student is less than 18 years)
August 2014
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