Northern Essex Community College
Section I (To be completed by the faculty member or field trip leader)
Faculty Member/Field Trip Leader:
Activity Date (s):
Equipment Needed:
Supplied by participant:
Supplied by Leader:
Activity to be undertaken includes:
Inherent risks and dangers associated with this activity: All risks associated with physical activity including risk of sudden death
Section II (To be read and completed by the student or, if student is under 18 years of age by a parent or legal guardian))
I acknowledge that I am seeking to participate in the voluntary activity (“activity”) described above. I further state that I am at least eighteen (18) years of
age, fully competent to sign this Agreement, and am voluntarily seeking to participate in this activity (or in the case of students under the age of 18, I
further state that I am the parent or legal guardian of the student identified below and am legally authorized to sign this form on behalf of the student who
is voluntarily seeking to participate in this activity). I understand that by signing this document I am representing that I understand all its terms and
conditions and fully intend to be bound by the same. I also understand that I may wish to consult with an attorney prior to signing this document.
I acknowledge that there may be certain dangers, hazards, and risks associated with my participation in this activity and I have reviewed the list of
inherent risks and dangers provided above. I further acknowledge and understand that all risks cannot be prevented. In light of the risks associated with
this activity, I have consulted with my physician and/or health care provider to discuss whether my participation in the activity is appropriate given my
current physical and mental health. Accordingly, I represent that I am physically and mentally able, with or without accommodation, to participate in this
activity, and am capable of using the equipment, if any, associated therewith.
On behalf of myself and my family (including legal guardians) I agree to assume all the risks and responsibilities surrounding my participation in this
activity, and agree to release from liability and waive any legal action against Northern Essex Community College, its governing board, officers, agents,
and employees (the parties), for personal injury, death, or property damage suffered by me while participating in this activity or while in transit to or from
the premises where the activity is being conducted.
I understand and agree that the College may not provide or have medical services or personnel available at the location of the activity or on its campus.
Therefore, should I require emergency medical treatment as a result of an accident or illness arising during this activity, I consent to such treatment.
Further, I acknowledge that the College does not provide activity participants with health or accident insurance and I agree to be financially responsible
for any medical bills incurred as a result of emergency medical treatment provided.
Further, I agree to comply with all rules and regulations included in the College’s Student Handbook and all other rules as set forth by the College
personnel during the activity.
I agree that this document shall be construed in accordance with the laws of the Commonwealth of Massachusetts. If any term or provision of this
document shall be held illegal or unenforceable, the remaining terms and provisions shall remain in full force and effect.
Student’s Name (Please print)
Signature (Signature of parent or legal guardian if participant is under
18 years old)
In case of an emergency, please contact:
Name & Relationship Phone Number