ACKNOWLEDGEMENT OF THE RISK FORM
I agree that as a participant in the ____________________________________________at
___________________________ associated with ________________________Community College
(the “College”) scheduled for __________________ to __________________, 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
slips and falls, injuries, and contracting diseases such as COVID-19, also known as the coronavirus
disease.
COVID-19 is a pandemic of respiratory disease that spreads from person-to-person. COVID-19
can cause mild to severe illness; most severe illness occurs in older adults. Nevertheless, people of all
ages with severe chronic medical conditions including, but not limited to, heart disease, lung disease,
and diabetes are also at a higher risk of developing serious COVID-19 illness. Healthcare workers
caring for patients with COVID-19 have a higher risk of exposure and I understand that the instructional
sites, labs, or clinical facilities may have people recovering from COVID-19. At this time, there is no
vaccine to protect against COVID-19 and no medications approved to treat it.
Symptoms of COVID-19 include fever, cough, and shortness of breath. Reported illnesses range
from very mild (including some with no reported symptoms) to severe, including death. If I feel sick, I
agree not to go to the instructional site/lab/clinical facility and that I will stay home, except to receive
medical attention if necessary. I also agree to take all necessary precautions recommended by the
Centers for Disease Control and Prevention, including but not limited to washing my hands thoroughly
and often, avoiding gatherings of ten or more people, covering my mouth and nose if I cough or sneeze,
and avoiding public transportation, ride-sharing, or taxis to the greatest extent possible.
I agree to abide by any and all specific requests by the College and the instructional
site/lab/clinical facility for my safety or the safety of others, as well as any and all of the College’s and
the instructional site/lab/clinical facility’s rules and policies applicable to all activities related to this
program. I understand that the College and the instructional site/lab/clinical facility reserve 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 or
illness which may occur as a result of my participation or arising out of my participation in this program,
unless any such personal injury or illness is directly due to the negligence of the College and/or the
instructional site/lab/clinical facility. I understand that this Acknowledgement 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 ______________________________________, at which time
my visits to or participation in the program will cease.
I have read and understand the risks involved in participating in an education program at an
instructional site/lab/clinical facility during this pandemic. I understand that I have the option to
postpone any clinical placement or on-campus assignment without academic penalty. I also understand
that I must complete the requisite number of clinical hours or other requirements to complete the health
professional or other academic program in which I am enrolled. If I choose to postpone any clinical
placement or on-campus assignment, I understand that my progression within the health professional or
other academic program will be delayed.
