Fillable Release from Liability, Behavior Standards, Medical Consent Form (Canada College)

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Release from Liability, Behavior Standards, Medical Consent Form (Canada College)

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San Mateo County Community College District
Release from Liability, Behavior Standards, Medical Consent Form
Event
Location
Event
Address
City State/Zip
Event Starts
(Day/Time)
Events Ends
(Day/Time)
Participant’s
Name
Participant’s
G-Number
Participant’s
Age
Address
City State/Zip
Email Phone
1. I acknowledge that the risk of injury from the activities involved in the Event is signicant, including the potential for a broken limb,
paralysis and fatal injury, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury still
exists;
2. I understand and acknowledge that the activities connected with the Event have inherent dangers that no amount of care, caution, instruction
or expertise can eliminate and I expressly and voluntarily assume all risk of death or personal injury sustained while participating in the
Event, whether or not caused by the San Mateo County Community College District, and its colleges, trustees, ocers, ocials, agents and/
or employees, other sport participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to
conduct the event or activity (the “Released Parties”).
3. I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation;
4. I willingly agree to comply with the stated instructions and policies and customary terms and conditions for participation. If, however, I
observe any unusual signicant hazard during my presence or participation, I will remove myself from participation and bring such to the
attention of the nearest ocial immediately;
5. I agree that I will not sue or make a claim against the Released Parties for damages or other losses sustained as a result of my participation
in the Event;
6. I agree to defend, indemnify and hold the Released Parties harmless from all claims, judgments, and costs, including attorneys’ fees,
incurred in connection with any action brought as a result of my participation in the Event;
7. I will take full responsibility for, and hold harmless the Released Parties, for any injury that I may suer or inict upon others or their
property as a result of my participation in the Event;
8. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and waive all my legal rights with
respect to the Released Parties in connection with any and all injury, disability, death, or loss or damage to person or property, to the fullest
extent permitted by law. I further agree that if, despite this Agreement, I, or anyone on my behalf, makes a claim for liability against any of
the Released Parties, I will indemnify, defend and hold harmless each of the Released Parties from any such liabilities which any may be
incurred as the result of such claim.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS,
UNDERSTAND THAT I HAVE RELEASED ANY AND ALL CLAIMS AGAINST THE RELEASED PARTIES RESULTING FROM
PARTICIPATION IN THE EVENT BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Signature (if Participant is under the age of 18, parentl/legal guardian signature) Date
Event Name (the “Event”)
Sponsoring/
Participating Group
Revised 3/23/2018
G
STANDARDS OF BEHAVIOR FOR OFF-CAMPUS ACTIVITIES
Students of the San Mateo County Community College District are expected to conduct themselves admirably and with respect for others, as the
actions of one individual can aect the reputation of the college and the campus organization participating in any o-campus event. During the
entirity of the event, the San Mateo County Community College District Policies and Procedures regarding Student Conduct, including Sections 7.69,
7.69.1, 7.69.2, and 7.69.3, and as listed in each college’s catalog, shall be observed.
Rules of Conduct and Behavior:
1. Alcoholic beverages or controlled substances are prohibited.
2. Engaging in harassing or disciminatory behavior based on nationality, religion, age, gender, gender identity, gender expression, race or ethnicity,
medical condition, genetic information, ancestry, sexual orientation, marital status, physical or mental disability, or on any basis prohibited by
law.
3. Fighting is prohibited.
4. Participants are expected to comply with any and all instructions by the advisor/chaperone.
5. Unless otherwise authorized, attendees are not to leave the Event premises without permission or being accompanied by an advisor or his/her
designee.
Consequences of Unacceptable Conduct and Behavior:
1. Use of alcohol and/or controlled substances may result in removal from the Event and referral to the College Disciplinary Ocer as stated in the
San Mateo County Community College District Student Conduct policy.
2. Failure to comply with directions of College/District ocials, faculty, sta, continued and willful disobedience or open persistence and deance
may result in removal from the event.
3. In the event that a student is sent home, said student shall be required to either cover the expense or reimburse the sponsoring campus
organization for the cost of travel, including changing the time and/or day of tickets.
I have read the Standards of Behavior listed above and agree to abide by them.
Signature of Student Date
MEDICAL CONSENT
I understand, agree and acknowledge that some activities may be of a hazardous nature and/or include physical and/or strenuous activity.
Understanding this, I state that I have no medical condition or impairment that might inhibit my safe and active participation in the above listed
activity. In addition, I understand that the University does not provide medical insurance coverage for activity participants and that any applicable
medical insurance must be provided individually by such participants. In the case of injury or medical emergency and in the event participant, or their
parent or guardian, cannot respond at the time of the emergency, the San Mateo County Community College District, acting through its employees
or agents, has permission to seek, administer, or have administered whatever rst aid or emergency medical care deemed necessary for participant’s
welfare, and it is understood that participant, and not the San Mateo County Community College District, shall be responsible for any and all charges
for such health care services regardless of whether participant’s medical insurance would cover such charges.
Further, the undersigned hereby certies that he/she has sucient personal health insurance to cover any activity related injury or illness.
In the event of any medical emergency, participant does _______________ (initials) authorize and consent to any x-ray examination,
anesthetic, medial, dental or surgical diagnosis or treatment and hospital care that the College program supervisor(s) deems necessary
for the safety and protection of the Participant.
Name of Health Insurance Carrier ____________________________________ Policy Number _______________________________
Are you currently under a physician’s care for any illness or injury, or do you have any allergies (circle one): YES NO
If yes, please explain:___________________________________________________________________________________________
Are you currently taking any prescription drugs (circle one): YES NO
If yes, please explain:___________________________________________________________________________________________
Person to be contacted in an emergency: ______________________________________ Phone: ______________________________
Printed Name of Participant Participant Signature
Printed Name of Parent or Guardian of Participant is under 18 Signature of Parent or Guardian if Participant is under 18
Revised 3/23/2018
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Release from Liability, Behavior Standards, Medical Consent Form (Canada College)

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Completed 2 February 2021

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