MCC Form STO 0011 (2.24.20)
STUDENT TRAVEL REQUEST
for field trips and student life
This form with all required paperwork must
be submitted at least 30 days before travel
Name of Event (purpose of travel)
Dates of travel Event/activity organizer
Name of Participant MCC ID#
Name of Course or Club traveling Campus
Waiver of Liability/ Assumption of Risk:
I agree that as a participant in a Mohave Community College (MCC) event or activity, I am responsible for my own behavior
and well-being. I accept this condition of participation, and I acknowledge that I understand the general nature of the risks
involved in this activity, including, but not limited to, personal injury or loss of personal property.
Initial
I understand that in the event of accident or injury judgment may be required by MCC personnel regarding what actions
should be taken on my behalf. I do hereby give and grant unto any medical doctor or hospital my consent and authorization
to render such aid, treatment, or care to myself as is judgment of said doctor or hospital that may be requested on an
emergency basis in the event I should be injured or stricken ill while participating in a class or activity sponsored by MCC. I
also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into
account my personal health and physical condition before participating in the event.
Initial
I further agree to abide by any and all specific requests by MCC personnel for my safety or the safety of others. I understand
that the College reserves the right to exclude my participation in the event my participation or behavior is deemed
detrimental to the health, safety or welfare of others.
Initial
In consideration for being permitted to participate, I agree to assume the risks involved. I hereby agree to hold MCC and its
officers, agents, employees, or the officers and members of any club or MCC organization harmless for any resulting personal
injury, damage to or loss of my property which may occur as a result of my participation, unless any such personal injury,
damage to or loss of my property is directly due to the negligence of MCC. I understand that the assumption of risk will
remain in effect during the entire event.
Initial
I am aware that MCC does not provide accident or health insurance coverage for me. I aware that I am not entitled to
worker’s compensation benefits while participating in any MCC sponsored event or activity. I am responsible for any health
care required as a result of my participation.
Initial
I understand that if I am under the age of 18 when this event/activity occurs I will need my parent/guardian to attend with
me. I will work with the organizer to ensure this requirement is met. A signed FERPA form giving my parent/guardian
permission to be informed of this event/activity is required.
Initial
I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal
risks and conditions of my own free will.
Initial
Participant Signature Date
If insured, name of medical insurance carrier*
*Attach photo a copy of insurance card to form
Emergency
contact name Emergency contact phone
click to sign
signature
click to edit
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