GS 89 (L) Form – Rev.5-20
LOS RIOS COMMUNITY COLLEGE DISTRICT
AGREEMENT TO PARTICIPATE AND WAIVER/ASSUMPTION OF RISK
NAME:_____________________________________ STUDENT ID NUMBER:_________________________________
CLASS/ACTIVITY:___________________________ INSTRUCTOR’S NAME:__________________________________
This is a release of liability and assumption of risk agreement. Read it carefully and sign below. Completion of
this form is
necessary in order to participate in this class activity.
I understand my decision to take this class or activity is optional and
voluntary. This document cannot be altered or modified by any verbal or written statements.
I am aware that participating in this Los Rios Community College District (DISTRICT) class or activity (including labs and/or
activities undertaken at home or off-campus for online courses) can involve MANY RISKS OF INJURY including, but not limited
to, property damage, bodily injury, personal injury and death.
In consideration of the DISTRICT permitting me to participate in the __________________________________________
class/activity, I hereby voluntarily assume all risks associated with my participation and release the DISTRICT, its employees and
volunteers, its colleges, campuses and centers, its governing board and the individual members thereof, and all other
DISTRICT officers, agents and employees from all liability (whether based on negligence or otherwise) for injuries (including
death) and damages arising out of or in any way related to the activity and/or class.
I understand that if this is/involves an excursion or field trip as defined by California Code of Regulations, Section 55220 that
Section states in part:
“All persons making the field trip or excursion shall be deemed to have waived all claims against the District or the
State of California for injury, accident, illne
ss, or death occurring during or by reason of the field trip or excursion.
All adults taking out-of-state field trips or excursions and all parents or guardians of minor students taking out-of-
state field trips or excursions shall sign a statement waiving such claims.”
By signing this Agreement, I hereby waive all such claims.
I understand and agree to accept all the rules and requirements of the activity and/or class, including safety rules and instructions given
by the supervisory personnel. I understand, and agree, and grant to the DISTRICT the right to terminate my participation in the
activity and/or class within the DISTRICT’s or DISTRICT’s employee’s sole discretion. If applicable, I understand and agree that
any costs associated with my return transportation shall be at my personal expense.
I consent to the DISTRICT providing emergency health assistance if it is determined necessary and further consent to the DISTRICT
notifying the emergency contact (listed below) and agree that this liability release and assumption of risk agreement applies to any of
the DISTRICT’s actions in this regard.
This agreement shall inure to the benefit of and be binding upon my heirs, decedents, successors, executors, assignees, legal
representatives, and all family members. The provisions of this agreement including, but not limited to, my waiver of liability and my
assumption of risk shall survive this agreement.
The following person should be contacted in case of an emergency: (please print)
-
Name Address Telephone No.
I/WE, THE UNDERSIGNED, HAVE READ THIS AGREEMENT AND UNDERSTAND THAT IT IS A RELEASE OF ALL
CLAIMS AND THAT I/WE ARE VOLUNTARILY ASSUMING ALL RISKS AND WAIVING ANY AND ALL CLAIMS
ARISING OUT OF OR IN ANY WAY RELATED TO THIS ACTIVITY AND/OR CLASS. I/WE AGREE THAT NO ORAL
REPRESENTATIONS, PROMISES, OR INDUCEMENTS, NOT EXPRESSLY CONTAINED HEREIN HAVE BEEN
MADE AND THAT THIS DOCUMENT CONSTITUTES THE ENTIRE AGREEMENT PERTAINING TO THE SUBJECT
MATTER CONTAINED HEREIN.
____________________________________________ ____________________
SIGNATURE Date
If participant is under 18, parent or
guardian must sign. ____________________________________________ _________________
__
_
PARENT OR GUARDIAN Date
