MT. SAN JACINTO COMMUNITY COLLEGE DISTRICT
Volunteer Activity/Excursion Form and Waiver
Directions: Fill in the following form, read and initial as indicated, and sign on page 2. Do not leave blanks!
Name of Activity/Excursion:
Name of Class/Club:
Location of Activity/Excursion:
Participant Name:
Activity Departure Date: Return Date:
Medical and Emergency Information:
In the event of illness or injury, I hereby consent to whatever medical treatment and hospital care is
deemed necessary for my safety and welfare from a licensed medical professional. It is understood
above
that any resulting expenses will be the responsibility of the activity Participant.
Unless indicated below, I certify that I have no known medical condition(s) which may pose a risk to
the health and safety of myself or others by participating in the activity(ies). I agree to advise the
above
District in writing below of any medical condition(s) which may be affected or in any way jeopardized
by participating in a specific field trip/excursion.
I have the following known medical condition(s):
Participant’s Medical Insurance Carrier Name:
Policy Number:
If no insurance, please indicate
Emergency Contact Information:
Name: Phone:
Name: Phone:
Indemnification and Waiver:
Per California Education Code Section 35330 and California Code of Regulations, Subchapter 5, Section 55450,
by participating in the field trip(s)/excursion(s), I understand that I waive all claims against the District, its officers,
agents and employees for any injury, accident, illness, or death occurring during or by reason of this field trip
or excursion, including acts of negligence by the District, its officers, agents or employees. The undersigned
hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for
personal injury, property damage or wrongful death occurring to him/herself arising as a result of engaging or
receiving instructions in said activity or any activities incidental thereto wherever or however the same may
occur and continue, and the undersigned does for him/herself, his/her heirs, executors, administrators and
assigns hereby release, waive, discharge and relinquish any action or causes of action, aforesaid, which may
hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or
his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property
damage or wrongful death against Mt. San Jacinto Community College District or any of its officers, agents or
employees for any of said causes of action, whether the same shall arise by the negligence of any of said
persons, or otherwise.
Volunteer Activity/Excursion Form and Waiver – Updated 050319 P a g e | 1
