ࡱ> 130y 0bjbj A"{{0xxxxx {}}}}}}$4xxx///:xx{/{///0)v?./g0/"//xC$/ >: WEST VALLEY-MISSION COMMUNITY COLLEGE DISTRICT VOLUNTARY ACTIVITIES PARTICIPATION FORM ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK ___________________________________________________ wishes to participate in the District-sponsored activities of ________________________________________________ I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate. I understand and acknowledge that some of the injuries/illnesses which may result from participating in these activities include but are not limited to the following: 1. Sprains/strains 5. Paralysis 2. Fractured bones 6. Loss of eyesight 3. Unconsciousness 7. Communicable diseases 4. Head and/or back injuries 8. Death I agree to assume liability and responsibility for any and all of the potential risks which may be associated with participation in such activities I understand, acknowledge, and agree that the District, its employees, officers, agents, or volunteers shall not be liable for any injury/illness suffered by me which is incident to and/or associated with preparing for and/or participating in this activity. Unless otherwise advised, I understand that I am responsible for my own transportation to and from the activity(ies) and the District assumes no liability for loss or injury resulting from my transportation. Although the college may assist in coordinating the transportation, any assistance and/or recommendations provided is not mandatory. If the District is providing transportation but I do not use the transportation, I am responsible to make my own transportation arrangements and the college assumes no responsibility or liability of any kind. I have no known medical condition which may pose a risk to the health and safety of others or me by participating in the activity(ies). I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION FORM/ACKNOWLEDGEMENT & ASSUMPTION OF POTENTIAL RISK form and that I understand and agree to its terms. ________________________________________________________________________ Student Signature Date ________________________________________________________________________ Parent/Guardian Signature (if necessary) Date A signed VOLUNTARY ACTIVITIES PARTICIPATION FORM must be on file with the extra-curricular/co-curricular activities. Voluntary Field Trip/Excursion Notice I UNDERSTAND THAT PURSUANT TO THE CALIFORNIA CODE OF REGULATIONS, SUBCHAPTER 5, SECTION 55450, BY PARTICIPATING IN THE VOLUNTARY FIELD TRIP(S)/EXCURSION(S), I AM DEEMED BY LAW TO HAVE WAIVED ANY CLAIMS AGAINST WEST VALLEY-MISSION COMMUNITY COLLEGE DISTRICT FOR INJURY, ACCIDENT, ILLNESS OR DEATH OCCURRING DURING OR BY REASON OF THE FIELD TRIP/EXCURSION. I FURTHER UNDERSTAND THAT PARTICIPATION IN A FIELD TRIP/EXCURSION IS VOLUNTARY. I AGREE TO ADVISE THE DISTRICT IN WRITING OF ANY MEDICAL, PHYSICAL OR HEALTH CONDITION WHICH MAY BE AFFECTED OR IN ANY WAY JEOPARDIZED BY PARTICIPATING IN A SPECIFIC FIELD TRIP/EXCURSION. In The Event Of Accident Or Illness Please Notify: Name: Address: Phone: (H) (W) I hereby acknowledge and understand that unless specifically advised otherwise, the District is not providing the transportation and it is my responsibility to arrange for my transportation to and from the activity. It is further understood that the driver of the vehicle in which I am riding is not driving on behalf or as an agent of the District, and the District has not verified the driving record of the driver, the liability insurance on the vehicle, or the condition of the vehicle. I understand that the District is in no way responsible, nor does the District assume liability, for any injury or loss which may result from my transportation. Although the District may assist in coordinating the transportation and/or recommend travel time, routes, car pooling, or caravanning, I understand that any recommendation(s) or travel assistance provided is not mandatory. 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