ALLAN HANCOCK COMMUNITY COLLEGE
VOLUNTARY ACTIVITY PARTICIPATION WAIVER
RELEASE OF LIABILITY and MEDICAL TREATMENT AUTHORIZATION
Unpaid internship or Work Experience, Cooperative Work Experience Education
Date(s) of Activity (Class Term):
Activity Program/Department and
CWE – Christine Espinoza, Ext. 3421
I understand and acknowledge that I have voluntarily enrolled in the Allan Hancock Community College Cooperative Work Experience Education course
and related Activities. I authorize the District to contact and visit my worksite supervisor to inform them of CWE course requirements and to notify
them if I fail to complete the enrollment process, drop the course or are dis-enrolled for any other reason.
I understand and acknowledge that this Activity and any related activities, by their very nature, pose the potential risk of serious injury/illness to
individuals who participate in such activities. I also realize that the Activity may be strenuous, and that I have the option to seek the advice of a
physical before I participate in this Activity. I understand and acknowledge that some of the injuries/illnesses which may result from participating in this
Activity include, but are not limited to, the following:
▪ Sprains ▪ Head and/or back injuries ▪ Loss of eyesight
▪ Fractured bones ▪ Paralysis ▪ Communicable diseases
▪ Unconsciousness ▪ Activity related injury/illness ▪ Death
The above list is not intended to be inclusive of all injuries that may occur, but rather to inform me of the types of risks inherent in my participation in
the above Activity, so that I can make a voluntary choice to participate or not participate.
In the event that this Activity is off campus, I hereby acknowledge and understand that, unless specifically advised otherwise, the District is not
providing transportation and it is my responsibility to arrange for my transportation to and from the Activity. If District does provide transportation but I
do not use the transportation, I am responsible to make my own arrangements and the District assumes no responsibility or liability of any kind. When
providing my own transportation, I further acknowledge and agree that:
The driver of the vehicle in which I am riding, either as driver or passenger, is not driving on behalf of, or as an agent of, the District and that
District has not verified the driving record of the driver, the liability insurance on the vehicle, or the condition of the vehicle;
The District is in no way responsible for, nor does District assume any liability for, any injury or loss which may result from my transportation.
In the event of accident or illness, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment
and hospital care considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a
member of the medical staff of the hospital or facility furnishing medical or dental services. Further, I agree that the District and its personnel are not
legally or financially responsible or liable for any claim arising from any consent given in good faith in connection with diagnosis or advised treatment.
In the event of accident or illness please notify: _________________________________________ ________________________________________
I voluntarily waive any claims against the District for injury, accident, illness or death occurring during or by reason of these Activities. I voluntarily
elect to participate in these Activities. I agree to assume any and all liability and responsibility for any and all potential risks which may be associated
with participation in such Activities or any Activities incidental thereto. I hereby voluntarily exempt and relieve, on behalf of myself and my heirs,
executors, administrators and assigns, the Allan Hancock Community College District, its officers, agents, servants, employees, and volunteers from any
liability or responsibility for any property damage, personal injury, bodily injury, or wrongful death that I might sustain which is incident to and/or
associated with preparing for and/or while participating in any Activity in any way connected with said Activities, including travel to and from Activity
locations, whether same shall arise by the negligence of any of said persons, or otherwise.
I acknowledge that I have carefully read and understand this Voluntary Activities Participation Waiver, Release of Liability and Medical Treatment
Authorization and that I agree to its terms and conditions.
Signature of Participant or, If Participant is a minor, Parent/Guardian Date
Print Name of Participant or, if Participant is a minor, Parent/Guardian Date
Sign, scan and submit as an email attachment to your CWE Instructor