COLLEGE-SPONSORED OFF-CAMPUS LEARNING EXPERIENCE
ACKNOWLEDGEMENT OF RISK AND CONSENT FORM
This Agreement must be signed by the student and reviewed by the Faculty
Supervisor before the first day of site placement.
SECTION
I (TO BE COMPLETED BY STUDENT AND REVIEWED BY FACULTY SUPERVISOR)
Off-Campus Learning
Site:
___________
Faculty Supervisor Name:
___________
Course Number and Name (if applicable):
___________
*** Please note: any experiences for which a student is to receive course credit always has tuition and fees attached. ***
Off-Campus Learning Experience
Activities
include
but
are
not
limited
to:
________
________
________
________
SECTION II (TO BE COMPLETED BY THE STUDENT)
I understand that there are certain dangers, hazards and risks that may be associated with my participation in the off-campus learning
experience activity(s) described above. I further understand that all risks cannot be prevented. I have considered the risks associated
with participating in this off-campus learning experience and knowingly and voluntarily assume all such risks. Furthermore, I
represent that I am physically and mentally capable of participating in this off-campus learning experience and that I am capable of
using the equipment, if any, associated with the off-campus learning experience.
On behalf of myself, and my family, heirs, assigns, and personal representatives, I hereby agree to indemnify, hold harmless, release
from liability and waive any legal action against the College, its governing board, officers, agents and employees (collectively, “the
Released Parties”) for any personal injury, death, or property damage I may suffer or cause to a third party arising out of or in
any way connected to my participation in the off-campus learning experience or while in transit to or from off-campus learning
experience.
I represen
t that I am covered by adequate medical/health/accident insurance for any injury that I may suffer at off-campus learning
experience site. In the event I require medical services due to an injury suffered during the off-campus learning experience, I
understand and agree that the College does not provide medical services or medical personnel at the off-campus learning experience
site and is under no obligation to provide transportation for me to obtain medical services.
I under
stand and 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 invalid or unenforceable, the remaining terms and provisions shall remain
in full force and effect. I understand that by signing this document I am representing that I have read and understand all of its
terms and conditions and that I 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.
Student’s
Name (printed):
___________
Student’s
Signature:
Date:
A copy of this form must immediately be placed on file with the Career Development Counselor.
A copy of this form was forwarded to the Career Development Counselor (Grossman Commons 206E) on (date): _____________
Initials______
Approved by MCCC and CCCC Administration October 10, 2017
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