Fillable Conf-Attendance-Medical-Consent-and-Release-Form Medical Consent

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Conf-Attendance-Medical-Consent-and-Release-Form Medical Consent

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Rev. 10.1.15
321 Golf Club Road
Pleasant Hill, CA 94523
(925) 969-4269 or (925) 969-4268
http://www.dvc.edu/studentservices/student-life/forms.html
Conference Attendance Agreement
Student Name (Please print) Student ID #
Telephone Email Address
Street Address City, State, Zip
Conference Name Conference Date(s), Location
I understand that I am attending this conference as a representative of my college and that my
expenses are paid in full or part by the college and/or the Associated Students. I understand that I am
expected to conduct myself in a responsible manner and agree to the following:
• I a
m currently enrolled at the respective college I am representing.
• No unauthorized personal vehicles are permitted to be driven to the conference without
approval of the advisor.
• I am aware that the California State Education Code and the policies of my District
prohibit possession or use of alcoholic beverages during the college function,
regardless of attendee’s age. (Prescriptions should be registered when turning in your
application, for your own protection).
• I understand that no inappropriate behavior will be permitted, nor any behavior that would
endanger the undersigned, or others. I also understand that I am responsible for any damages I
cause to any facility while attending this conference.
• I agree I will not invite any outside visitors to participate in conference activities without having
obtained prior approval from my advisor.
• I understand that this is an official field trip and that I am required to attend all possible work
sessions.
• I understand that any infraction may result in possible disciplinary action and immediate
dismissal from the conference and that I will then become responsible for making other
arrangements for my return to the college.
• All participants must stay within the designated areas announced.
• Any exceptions must be approved by the advisor one week prior to the event date.
In addi
tion, I understand that this Conference Attendance Agreement Form must be turned in by the
time designated by the advisor and before the event date.
Signature of Student Signature of Advisor
Print Name of Student Print Name of Advisor
Date Date
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Rev. 10.1.15
321 Golf Club Road
Pleasant Hill, CA 94523
(925) 969-4269 or (925) 969-4268
http://www.dvc.edu/studentservices/student-life/forms.html
MEDICAL CONSENT
In
the event of any medical emergency, I grant to the College or any of its representatives on the trip
the full authority to take any action deemed necessary to protect my health and safety at my expense,
including but not limited to, placing the Participant under the care of a doctor or in a hospital at any
place for medical examination and/or treatment, or returning the Participant to their home city at his or
her own expense if such return is deemed necessary after consultation with medical authorities.
Nam
e of Student: ____________________________________________
(I
nitial one of the following statements):
_________ I am 18 years of age or older and am the participant.
My birth date is: _____________
_________ I am
the parent or legal guardian of participant who is under 18 years of age to whom
the above statements apply and for whose benefit I am executing this Agreement.
I hav
e read the consent agreement and I understand its terms. I execute it voluntarily and with full
knowledge of its significance.
____________________________________________________ ____
________
Signature of Participant or Participant’s Parent or Legal Guardian Date
_________________________________ ___________________
____________
Print Name of Signatory Address
_________________________________
_______________________________
Student ID# Phone #
Diablo Valley College
College Name
In c
ase of emergency please contact: ________________________________________
Relationship: ____________________________ Phone No.: ____________________
Med
ical Insurance Carrier: _______________Policy #: __________________________
Lis
t any prescription medications you are currently taking: ________________________
______________________________________________________________________
Lis
t all allergies (food, medication and other): __________________________________
______________________________________________________________________
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Rev. 10.1.15
321 Golf Club Road
Pleasant Hill, CA 94523
(925) 969-4269 or (925) 969-4268
http://www.dvc.edu/studentservices/student-life/forms.html
CONTRA COSTA COMMUNITY COLLEGE DISTRICT
CONSENT AND RELEASE EVENT
In consideration of being permitted to participate in _____________________________________
(describe program)
at____________________________________________________on
__________________________
(location) (date)
I he
reby represent that I will obey and uphold all of the rules and requirements established by Diablo
Valley College and Contra Costa Community College District, observe all program schedules and
follow all directives given to me by supervisory personnel in all matters pertaining to the event. I grant
to Diablo Valley College and Contra Costa Community College District the right to terminate my
participation in the event if it is determined that my conduct is detrimental to or in conflict with the event
or out of harmony with the best interests of the group as a whole, in which case I shall be sent home at
my own expense.
I
fully recognize and agree that Diablo Valley College and Contra Costa Community College District
cannot and will not be held responsible in any way for my safety, my needs or my well being during any
period in which I am not directly participating in the event.
I he
reby release and agree to indemnify the trustees of the Contra Costa Community College District
and Diablo Valley College and all of the agents, employees, officers and cooperating organizations of
the District or College, either in their individual capacities or by reason of their relationship to the
trustees or to the College, from all responsibility or liability or claims of any nature whatsoever for loss,
damage or destruction of property, or injury or death to person, due to any cause whatsoever occurring
during my participation in this event under the direction of Diablo Valley College. In addition, I fully
acknowledge that I am responsible for any injury, loss or damage to property, to myself and to others.
I gr
ant to Diablo Valley College, Contra Costa Community College District or any of its representatives
full authority to take any action deemed necessary to protect my health and safety at my expense, to
include but not limited to placing me under the care of a doctor or in a hospital at any place for medical
examination and/or treatment or returning me at my expense if such return is deemed necessary after
consultation with medical authorities.
I hav
e read the foregoing Consent and Release and, understanding its terms, I freely agree to all of the
provisions set forth therein.
Name Home Telephone
Signature Date
(Parent’s signature if under 18 years) Date
California Driver’s License # Vehicle License Plate #
Vehicle’s registered owner Insurance Company Policy No.
Emergency Contact Person Phone #
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Conf-Attendance-Medical-Consent-and-Release-Form Medical Consent

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Completed 6 March 2020

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