Assumption of Risk and Liability Release
Please fill out this form and take it with you to Great Bay Community College
Present it to the One Stop along with your signed, course registration form
Participating Student Last Name First Name Middle Name
Date of Birth:
MM/DD/YYYY Home Phone Email
Grade Level: 11
Goal College: __________________ Goal Career: ____________________
_______________________________________________ Anticipated Graduation Date: _________/____/__________
High School Name
Type of School: Public High School Private School Home School
GBCC term student is scheduled to attend:
Fall Spring Summer Year: _______
High School Counselor recommended GBCC course(s):
GBCC Course Name and Number GBCC Course Title
GBCC Course Name and Number GBCC Course Title
*Limit of two classes per semester*
1. Credit courses are COLLEGE courses and will remain on the student’s permanent college record.
2. We understand that the College will have specific rules that will apply to the student's ability to enroll and
attend. These rules may include, but are not limited to, certain enrollment prerequisites, registration
requirements, placement tests, matriculation status, and access to "remedial" or "developmental" courses.
3. We understand that there will be no supervision provided for students prior to or after classes.
4. We understand that the coursework has college level content which may include mature material.
5. We understand that the College is authorized to evacuate students in case of an emergency.
6. We understand that students must adhere to the College’s Student Code of Conduct.
7. I understand that I am responsible to pay 50% of the actual tuition for GBCC courses. I also understand I am
responsible for the cost of books and materials and associated fees.
8. The undersigned parent/guardian hereby grants permission for participating student to enroll in the above
listed courses at the specified CCSNH College.
9. We represent that the participating student though not yet 18 years of age is sufficiently mature to manage a
college campus environment and participate in college level courses.
10. The undersigned parent/guardian understands that the Family Education Rights and Privacy Act (FERPA)
governs all college education records and allows release of academic information, including grades, to the
student only, regardless of age. Academic information cannot be released to parents or third parties without
the written consent of the student.
11. We understand and agree that the College will treat the participating student as an adult; that we have had a
reasonable opportunity to consider the risks of a minor student participating in the adult and independent
learning environment of the College, including all risks of related to entering onto a campus where
supervision is not provided and engaging in coursework that may include adult themes, topics and
discussions; and that we assume all such risks regarding the participating student's participation at the
College. On behalf of the same and to the full extent permitted by law, the undersigned parent and minor
further release, hold harmless, indemnify and covenant not to sue the CCSNH and its colleges and/or their
governing boards, trustees, employees and any agents from and against any and all liability for harm, injury,
damage, claims, demands, actions, causes of action and expenses of any kind that we may have or that may
hereafter accrue to us, directly or indirectly, related to any loss, damage or injury that we may sustain from
the minor student's participation at the College.
Parent/Guardian Signature Date
Participating Student Signature Date
1. The student listed is a Junior or Senior and is a regularly enrolled student at our school and has permission to
take the above course(s) at GBCC.
2. The student is able to benefit from advanced scholastic or vocational work at GBCC.
3. The GBCC course(s) selected will also satisfy a high school requirement.
Guidance Counselor Name (Please Print) Phone
Guidance Counselor Signature Date
High School Phone: ________________________
For Information or Questions:
Office of Admissions
603-427-7600 Ext 7500
For Returning Students:
Advising Center
The Community College System of New Hampshire (CCSNH) uses electronic signatures and records in place of traditional ones whenever possible. You will conduct business electronically using a computer with a supported
operating system and internet browser, sufficient electronic storage capacity, a printer and your official CCSNH email account. By logging into CCSNH systems, including but not limited to Banner, SIS and Canvas, you are opting to
conduct electronic transactions with the Community College System and consenting to receive written notices electronically, including those involving financial obligations, and you are acknowledging that CCSNH can use
electronic mechanisms alone to convey critical information related to your admission, financial aid, payment plan, student account, transcript information, registration and other activities and accounts you may undertake or have as
a student at CCSNH. You have a right to request a paper copy of an electronic record. You may withdraw your consent at any time by contacting Student Services. If you decide to withdraw your consent, however, you may be
prevented from registering for classes.
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