AIR TRAVEL NOTIFICATION FORM
Dear
,
(Student’s Name)
You are currently participating in a California State University-affiliated program which requires air travel.
Air travel involves risks and could result in damage to property, injury to persons, and death. Please be informed that the California
State University assumes no liability for damage, injury, and death which may occur during air travel required by the California State
University-affiliate programs. Your participation in the program is voluntary, and you participate at your own risk.
Prior to undertaking CSU-affiliated air travel, you will be required to sign the below “Release and Hold-
Harmless Statement.” Please review the statement carefully before signing it.
Faculty Name (Please Print) Faculty Signature
RELEASE AND HOLD-HARMLESS STATEMENT
I,
, am a student at California State University, Channel Islands, one of the campuses of the
California State university (CSU).
I am/will be participating in a CSU-affiliated program which requires air travel. (CSU-affiliated program includes any program
offered by, or pursuant to a program of, the California State University, any campus of the California State University, any student
body organization, or any organization affiliated with any such organization or with any combination thereof.) My participation in
this program is voluntary.
I have been informed, and I know, that 1) air travel involves risks which can result in damage to property, injury to persons, and death;
and 2) the CSU assumes no liability for damage, injury, or death occurring on such travel. With this knowledge and information, I
agree to participate in the program, and the air travel, at my own risk.
I release and hold harmless the state of California, the California State University, California State University, Channel Islands, and
each and every officer, employee, volunteer and agent of each of them, from any and all claims and causes of action that I may have
against any of these institutions or persons, by reason of any accident, illness, injury, death, or other consequences resulting directly or
indirectly from or in any manner arising out of, or in connection with, my being a passenger on an airplane pursuant to my
participation in the CSU-affiliated program.
This release and hold-harmless shall also be binding on my heirs, assigns, successors, and all other persons who
may claim through me.
Student Signature Print Name Date
Street Address
City State Zip Code
