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Diablo valley VOLUNTARY ACTIVITIES PARTICIPATION FORM POTENTIAL RISK

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Diablo Valley College Student Life Office
Rev. 10.1.15 S:\Voluntary-Activities-Participation-form.pdf
VOLUNTARY ACTIVITIES PARTICIPATION FORM
ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK
I __________________________, agree to participate in the District sponsored activities of
(Name)
__________________________ on _______________________________.
(Name of activity/event) (Date)
I under
stand and acknowledge that some of the injuries/illnesses which may result from
participating in these activities include, but are not limited to, the following:
1. Sprains/strains 5. Paralysis
2. Fractured bones 6. Loss of eyesight
3. Unconsciousness 7. Communicable diseases
4. Head and/or back injuries 8. Death
I under
stand and acknowledge that participation in these activities is completely voluntary and
as such is not required by the Student Life Office, Diablo Valley College, or the Contra Costa
Community College District for course credit or for completion of graduation requirements.
I under
stand and acknowledge that in order to participate in these activities, I agree to assume
liability and responsibility for any and all potential risks which may be associated with
participation in such activities.
I
understand, acknowledge, and agree that the Student Life Office, Diablo Valley College, or the
Contra Costa Community College District, its employees, officers, agents, or volunteers shall
not be liable for any injury/illness suffered by me which is incident to and/or associated with
preparing for and/or participating in this activity.
I ac
knowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION
FORM and that I understand and agree to its terms.
_______________________________________________ ________________________
Participant Signature Date
_______________________________________________ ________________________
Parent/Guardian Signature if participant is under 18 years old Date
A s
igned VOLUNTARY ACTIVITIES PARTICIPATION FORM must be on file with the District
before a student will be allowed to participate in the above extra-curricular activities.
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Diablo valley VOLUNTARY ACTIVITIES PARTICIPATION FORM POTENTIAL RISK

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Completed 7 March 2020

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