RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT
STUDENT PARTICIPANT - COLLEGE ACTIVITY
Student/Participant Name Department/Club Name
Student/Participant Number Date of Birth
Emergency Contact Name Emergency Contact Phone#
Assumption of Risks: Participation in:
Describe
Activity
carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid
injuries. I hereby assert that my participation is voluntary and that I knowingly assume all risks in
consideration of the educational benefit to be derived by me.
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,
heir, executors, and administrators for loss of property, personal injury or death sustained
by me arising out of any travel or activity, however caused, conducted by or under the
control of Palm Beach State College. I further understand that this Release applies if I
decide not to travel with the College group in a College-approved vehicle and use my own
personal means of transportation to and from the College sponsored event. I will notify my
advisor of my departure to and arrival at the College sponsored event, as well as upon my
return from the event. It is understood that Palm Beach State College, as used herein, shall
include the employees, administrators, agents and District Board of Trustees of Palm Beach
State College.
Date Signature of Student/Participant
For students/participants under the age of 18:
I HEREBY APPROVE THE FOREGOING AGREEMENT AND JOIN IN THE FOREGOING
RELEASE.
Date Signature of Parent
Palm Beach State College is self insured per Florida Statute 768.28 - $200,000 per person/$300,000 per occurrence aggregate
Health Insurance Provider
Health Insurance Policy #/ Phone #
