SOUTHWESTERN COMMUNITY COLLEGE DISTRICT
EXCURSION LIABILITY RELEASE & AGREEMENT FORM
Excursion Site:
Location:
(Street Address, City, State)
Club/Organization:
Event Date:
Event Time:
Activity/Event Title:
Activity Request No.:
Supervising Faculty/Advisor:
Phone Number:
Email:
.
Student Name:
Last Name: First Name:
SWC ID No.:
Email:
Phone Number:
Age:
(If below 18, fill out box below)
Print Name of Parent or Legal Guardian:
Last Name: First Name:
Parent
Legal Guardian
Signature of Parent or Legal Guardian:
Date:
Phone Number:
Completion of this form is required for participation by students/non-students in any and all Off-Campus field trips, tours, club activities, or any other special event sponsored by the
Southwestern College District. No one will be permitted to attend/participate in the excursion specified above unless this form has been completed, approved and signed by the
participant, faculty/staff Supervisor, and Director of Student Development no later than the day of the excursion. The completed and signed form is to be forwarded to the Office of
Student Activities.
The Southwestern Community College District (“District”) grants the student mentioned above, and who has read the information below and have signed this form, to have
permission to participate in the excursion specified above.
In consideration of the permission granted by the District of the Participant(s) to participate in the excursion named above, the undersigned, understand and agree as follow:
Release and Indemnification In accordance with Title 5, California Code of Regulations section 55450, and in consideration of my participation in said excursion, I hereby release the
Southwestern Community College District, its officers, employees, and agents from and waive all claims for injury, accident, illness, death, loss of property, or property damage
occurring during or by reason of said excursion, except for any claims based upon fraud, willful injury to person or property, or violation of law, by the District, its officers, employees,
and agents, and further agree to indemnify and hold harmless the District, its officers, employees, and agents from any claims and actions for damage or injury which any person may
assert by reason of my conduct while participation in said excursion.
Rules and Requirements Agree to accept all rules and requirements of the excursion; observe the designated schedule and follow the instructions given by the District’s supervisory
personnel in all matters pertaining to the excursion. I grant the District, acting by and by them that my continued participation in detrimental to or in conflict with the purpose of the
excursion, or is not in harmony with the best interests of the other participants and/or supervisory personnel. Violation of any of the stated ruled or regulations pertaining to his
excursion will result in my immediate removal from said excursion.
Medical Consent In a medical emergency arising during the course of the excursion, I grant to the District acting through it designated supervisory personnel full authority to take
any action deemed necessary to protect my health and safety at my expense, including but now omitted to placing me under the care of a doctor, hospital, and/or other qualified
medical personnel to examine and/or treat me.
Injury/Illness If you become ill or injured while taking part in a class-related excursion, you may have secondary medical coverage under Student Health Insurance. Immediately
upon your return from the excursion contact Health Services, Ext. 6354 for Medical coverage information and claim form(s).
Drug and Alcohol Statement Use, possession, sale, distribution, or manufacture of, or the attempted sale, distribution or manufacture of alcohol and drugs on college properties or
at official college functions is unlawful or otherwise prohibited by college policy or campus regulations.
Participants If the participant is younger than 18 years of age, this form must be signed by the participant’s parent or legal guardian. Minors may not participate in any international
travel/activity.
I have read this liability release and understand and agree to its terms and conditions. I execute it voluntarily and with full knowledge of its content, ramification
and my responsibilities thereof as evidenced by my having signed below.
_____________________________________________________________________ ______________________________________________________
STUDENT SIGNATURE DATE
I hereby authorize the individual listed on this form to participate in this excursion with the terms and conditions described above and affirm that I personally
observed the student signing this form.
_____________________________________________________________________ ______________________________________________________
SIGNATURE, Faculty/Advisor DATE
I hereby authorize the individual listed on this form to participate in this excursion with the terms and conditions described above.
_____________________________________________________________________ ______________________________________________________
SIGNATURE, Director of Student Development DATE
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SOUTHWESTERN COMMUNITY COLLEGE DISTRICT
GENERAL INFORMATION
Participant’s Name: _____________________________________________________________________________________ Gender Identity: ____________________
Last Name First Name Middle
Home Address: _____________________________________________________________________ Email: _____________________________________________________
Street City State Zip Code
Phone Number
(with area code)
__________________________________ SWC ID Number ______________
Please list any accommodations you are requesting for this activity due to disability:
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Dietary needs/restrictions. Please list any dietary needs due to personal or religious beliefs, or food allergies:
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Lodging. Students are asked to share rooms/cabins with students of the same gender. Please list the gender identity you are
comfortable rooming with: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
HEALTH INFORMATION
List any health problem or medical condition that could adversely affect your participation in this activity. For example:
heart disease, diabetes, high blood pressure, epilepsy, allergies, etc. _____________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Please list any prescription drugs you are currently taking: ________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Do you have any allergies to medication/other (e.g. antibiotics, bee sting, etc.)? Yes No
If yes, please explain:_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name_____________________________________________________ Local Address _________________________________________
Phone Number__________________________________________ Relationship ________________________
Notice: Use, possession, sale, distribution, or manufacture of, or the attempted sale, distribution or manufacture of alcohol
and drugs on college properties or at official college functions is unlawful or otherwise prohibited by college policy or
campus regulations.
Signature of Participant : _________________________________________________ Date: __________________________
Signature of Parent or Legal Guardian* : _______________________________ Date: __________________________
*If the participant is younger than 18 years of age, this form must be signed by the participant’s parent or legal guardian.
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