South Puget Sound Community College
Office of Student Life
Informed Acknowledgement of, and Consent to Risks, and Release of Liability
Activity/Event Name: Location:
Departure Date and Time: Return Date and Time:
I am aware that during this activity/event certain dangers may occur. Participation in this activity or event may involve injury of some
type to either me or a fellow participant. Such injury can include direct physical and possibly crippling injury or death to me, and the
possibility of emotional injury experienced as a result of witnessing or actually inflicting injury or death to another. The severity of such
injury can range from minor cuts, scrapes, or muscle strains to catastrophic injury, such as complete paralysis or even death. Such
injury can impair my general physical and mental health and hinder my future ability to learn, to earn a living, to engage in other
business, social and recreational activities, and generally to enjoy life.
The purpose of this WARNING is to bring to your attention the existence of potential dangers associated with this activity or event.
There is, however, always the risk of other types of injuries or the risk of injury or death resulting from other causes not specified here. I
understand that neither the College nor any of its agents or instructors serve as guardians or insurers of my safety, and that the
College does not provide any insurance, regular nor special, for my protection. In consideration of, the right to participate in the activity
or event and the services arranged for me by South Puget Sound Community College, by signing this form I acknowledge I am willing
to and do voluntarily and knowingly assume all the above mentioned risks and any other risks arising from my participation in the
activity. I am doing this of my own free will. For and in consideration of the opportunity to participate in this activity or event, I, on my
own behalf and on behalf of my heirs, assigns, executors, administrators, all members of my family, and other successors in interest,
do hereby release and forever discharge the STATE OF WASHINGTON and its officers, agents, employees, agencies and
departments, including but not limited to SOUTH PUGET SOUND COMMUNITY COLLEGE, from any and all existing and future
claims, liability, debts, demands, damages and causes of action of any nature whatsoever, including serious bodily injury or death,
which may arise out of my participation in this event or activity. This is a final, conclusive and complete release of all unknown and
unanticipated damages arising out of my participation in this event or activity, as well as those now known or disclosed (Parent or
legal guardian must sign for all persons under eighteen (18) years of age.)
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS INFORMED CONSENT AND RELEASE BY READING IT
BEFORE SIGNING IT. I EXECUTE IT AS CONSIDERATION FOR THE RIGHT TO PARTICIPATE IN THE EVENT OR ACTIVITY,
WITH FULL KNOWLEDGE THAT BY SIGNING IT I HAVE WAIVED LEGAL RIGHTS THAT I WOULD OTHERWISE HAVE BEEN
ENTITLED TO ENFORCE. I UNDERSTAND IT AND VOLUNTARILY ACCEPT IT, ON MY OWN BEHALF OR ON BEHALF OF MY
CHILD.
Signature of Participant Date of Birth Date
Signature of Parent or Legal Guardian (If participant is under 18 years of age) Date
Participant Information (Print)
Name: Phone:
Address:
Allergies: Medications:
In Case of Emergency Notify (Name):
Relationship: Phone:
