Last updated March 10, 2020
Waiver and Release of Liability for Student Activity or Course-Related Field Trip
Part 1. Student Information
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_____________________ _____________ ________________ ________________
Student Full Name Student ID # Date of Birth Phone Number
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_____________________________ ________________ ____________________________
Activity Date of Activity Course Name/Section, if applicable
(ex. PSYC 299, sec. 14)
Part 2. Medical Information
P
lease list any current medial conditions or allergies. __________________________________________
Medical Insurance: ☐ GuardMe Policy # _______________________________
☐ MSP Personal Health # _______________________________
Please indicate an emergency contact person who Columbia College staff should contact. This must be a
local individual who would be able to come to your aid in the case of emergency.
______________________________ _____________________ ________________________
Emergency Contact Full Name Relationship to Student Phone Number
Part 3. Student Consent
In consideration of being permitted to participate in this activity or course-related field trip (hereinafter collectively
referred to as “the Activity”), I agree, for myself, my heirs, administrators, personal representative, and/or assigns,
that I do hereby release, hold harmless, and discharge Columbia College, its officers, trustee, employees, agents and
others acting on its behalf (hereinafter collectively referred to as “officials”), from all claims, demands, causes of
action and legal liability, whether the same be known or unknown, anticipated or unanticipated, brought as a result of
my involvement in this Activity.
Although proper protocol and care will be taken by Columbia College, I hereby acknowledge the risks involved in
participating in this Activity, including travelling to and from Columbia College and/or points along the way.
I hereby further assure officials at Columbia College that there are no health-related reasons or problems which
preclude or restrict my participation in this Activity.
I agree to adhere to the Columbia College Code of Conduct when participating in this Activity (Columbia College
Calendar, Code of Conduct, available on https://www.columbiacollege.ca/).
I agree to waive any and all claims, liability and damages against Columbia College and its officials with respect to any
accident or loss of property that might occur in connection with this Activity.
☐ I a
cknowledge that by signing below I confirm that I have read this waiver and release of liability and
accept its terms. I express my wish to participate in the above stated activity.
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________________________ __________________________
Signature of Student Today’s Date
Part 4. Parent/Guardian/Custodian Consent (For Minor Students Under 19 Years of Age)
☐ I a
cknowledge that by signing below I confirm that I have read this waiver and release of liability and
accept its terms. I consent for the minor student under my care to participate in the above stated activity.
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_________________________________ ___________________________________
Signature of Parent/Guardian/Custodian Printed Name of Parent/Guardian/Custodian
