I have registered for Summer Kids’ or Teen College classes sponsored by the College of
I understand that participation in this activity/course involves inherent risks of injury, and that the nature of
the risks may vary depending upon the type of activity, instructor, and my own physical condition and conduct. I
also understand that it is not possible to specically list each and every individual risk, but that most courses and
activities may involve risks associated with strenuous exercise, as well as risks from the usage of equipment or
participation in group activities. I acknowledge that I will either ask for or have been given any information that I
need to determine the general risks associated with this course/activity.
I understand that I will complete a written self-evaluation of my health status to help determine whether I must
seek a physician’s permission before participating in this course/activity, but that it is ultimately my responsibility
to determine whether I can safely participate in this course/activity. I understand and agree that if the college
determines, based upon the results of the initial evaluation, that a medical clearance is necessary, that I will not
be allowed to participate in any physical activities that are part of this course/activity until I have consulted with
my physician and obtained written permission.
I understand that certain precautions may be advised for the particular course/activity. I agree to follow those
precautions and to conform to all rules and policies of the department, the instructor, and any other sponsor
of this course/activity. However, I recognize that these precautions will not eliminate the risks inherent in this
I voluntarily assume all risks of loss, damage, illness, or injury which I may sustain while participating in this
course/activity, including travel and usage of or any equipment or facilities. I will make no claim against and
release, waive, discharge, hold harmless and indemnify, on behalf of myself, my personal representative and my
heirs, the College of Southern Maryland and its ofcers, agents, and employees for any and all claims and causes
of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or result
from my participation in this course/activity, whether arising through the negligence, omission, default, or other
action of any person or event associated with this course or event, including fellow participants.
I agree that all disputes, controversies, and claims that may arise between myself, my personal representative
or my heirs and the College of Southern Maryland or its ofcers, agents and employees relating to or arising out
of this Statement of Informed Consent, Assumption of Risk, and Release (including but not limited to disputes,
controversies, and claims related to or arising out of the activity set forth above) will solely be resolved by nal
and binding arbitration administered by the American Arbitration Association. Except as may be required by
law, neither a party nor an arbitrator may disclose the existence, content or results of any arbitration hereunder
without the prior written consent of both parties. Judgment on an award rendered by an arbitrator may be
entered in any court having jurisdiction thereof. My agreement to nal and binding arbitration shall in no way be
construed to limit any other provision of this Statement of Informed Consent, Assumption of Risk, and Release.
I have read and understand the above information. I give my permission for my child to participate in this course/activity and
grant the same informed consent, assumption of risk, and release on behalf of myself, my child, and the child’s family.
College of Southern Maryland
Statement of Informed Consent,
Assumption of Risk, and Release
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH (month/day/year)
CITY OR TOWN COUNTY STATE ZIP CODE
PARENT OR GUARDIAN SIGNATURE DATE
CSM Kids’ and Teen College Registration Form (Page 5)