RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT
ACADEMIC STUDENT PROGRAM OFF-CAMPUS COLLEGE TRAVEL PERMISSION FORM
As a student or participant of a college function of Palm Beach State College, I do willingly execute this release in
consideration of the educational benefit to be derived by me and my participation in:
I hereby release from liability and hold Palm Beach State College harmless from any and all claims and causes of
action which might be brought by myself, parents, spouse, dependents, heirs, executors, and administrators for
loss of property, personal injury or death sustained by me arising out of any travel or activity conducted by or
under the control of Palm Beach State College. It is understood that Palm Beach State College, as used herein,
shall include the employees, administrators, agents and Board of Trustees of Palm Beach State College.
For students/participants under the age of 18:
I HEREBY APPROVE THE FOREGOING AGREEMENT AND JOIN IN THE FOREGOING RELEASE.
Student ID#:
Emergency Contact Name:
Student Name:
Emergency Phone#:
Name of Professor/Educator
Date of Birth:
Signature of Student/Participant:Date:
Signature of Parent/Guardian: _______________________________________
Date:
Print Name of Parent/Guardian: __________________________________________________________________
Describe Event
and Dates
Palm Beach State College is self insured per Florida Statute 768.28 - $200,000 per person/$300,000 per occurrence aggregate.
Academic Programs Use Only
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