Personal Liability Release
,a student at Luna Community College, hereby
agree to release Luna Community College, its representatives, agents, servants, and
employees from any liability for any injury resulting from any cause whatsoever occurring
while participating/attending the activity trip, including travel to and from activity, accepting
only such injury or damage resulting from willful acts of such representatives, agents,
servants, and employees.
I further understand that this release of liability applies should I wish to provide my own
vehicle for transportation or travel with someone else to and from the activity when
transportation to the activity is provided by Luna Community College.
I,
Student Name LCC Student I.D. #
Student Signature
Date
Date of Activity
NOTE: If student is under legal age of 18 years, parent(s) or
guardian signature is required:
Signature of Parent(s) or Guardian
Date
Specific Location
of Activity
Enter information below, print, sign and submit to Physical Plant Department
Print on WHITE paper
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signature
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click to sign
signature
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