RELEASE AND DISCHARGE FOR FIELD TRIPS OR OFF-CAMPUS ACTIVITIES
In consideration of
(Group)
of Illinois Valley Community College attending:
Activity:
Departure Date & Time:
Location:
Return Date & Time:
Hotel (if applicable): Hotel Phone #:
Airline (if applicable): Flight #:
and permitting me as a participant/guest of
and Illinois Valley Community College to take the trip, I do hereby Release and Discharge Illinois Valley Community College, its Board of
Trustees, the Administration, the Student Government, faculty, and agents from any and all claims, demands, and causes of action which
may accrue to me, my heirs, executor or assigns, as a consequence of, and resulting from, my taking the trip, including personal injury or
property damage which I may sustain in the course of such trip.
I acknowledge that this service is being provided as a benefit to me and not for the benefit of Illinois Valley Community College. I
understand that Illinois Valley Community College will assume no responsibility for damage, accidents, injuries, or medical injuries
(including, but not limited to, broken bones, torn or pulled ligaments or tendons, back injury, or soft tissue injury) or death and/or dental
injuries/expenses incurred as a result of my participation in this trip.
I assume all responsibility for any damage that I may cause while participating in the trip. I release and waive, and further agree to
indemnify, hold harmless, and reimburse the Board of Trustees, the individual members, agents, employees, and representatives thereof,
from, and against, and claim which I, or any other person, firm, or corporation may have or claim to have, known or unknown, directly or
indirectly, for any losses, damages, or injuries arising our of my participation in the trip or the rendering of emergency medical procedures
or treatment, if any.
The driver of the vehicle provides the primary insurance coverage while on the field trip if they are using their personal vehicle.
Participant Name (please print legibly):
Participant/Guest signature: Date:
Parental consent for students under 18 years:
Emergency Contact (please print legibly):
Emergency Contact Phone #:
Trip/Event Supervisor's Name (please print legibly):
Trip/Event Supervisor's Signature: Date:
Date:
Participant/Guest Phone/Cell #:
