Assumption Of The Risk Form


I agree that as a participant in the _____________________________________ at ______________________________
associated with Piedmont Virginia Community College (the “College”) scheduled for __________to __________, I am
responsible for my own behavior and well being. I accept this condition of participation, and I acknowledge that I have
been informed of the general nature of the risks involved in this activity, including, but not limited to: _______________
I understand that in the event of accident or injury, personal judgment may be required by _________________________
or College personnel regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that the College
and/or ________________________ personnel may not legally owe me a duty to take any action on my behalf. 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.
I further agree to abide by any and all specific requests by the College and ________________________ for my safety or
the safety of others, as well as any and all of the College’s and ________________________’s rules and policies
applicable to all activities related to this program. I understand that the College reserves the right to exclude my
participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others.
In consideration for being permitted to participate in this program, and because I have agreed to assume the risks
involved, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of my property which
may occur as a result of my participation or arising out of my participation in this program, unless any such personal
injury, damage to or loss of my property is directly due to negligence of the College and/or ________________________.
I understand that this Assumption of Risk form will remain in affect during any of my subsequent visits and program-
related activities, unless a specific revocation of this document is filed in writing with (program coordinator or College
administrator), at which time my visits to or participation in the program will cease.
In case an emergency situation arises, please contact ____________________________ at ________________________.
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.
I represent that I am 18 years of age or older and legally capable of entering into this agreement.
Participant’s signature
If participant is less than 18 years of age, the following section must be completed.
My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this
program, and I agree to be responsible for his/her behavior and safety during this event.
Child’s Name
Parent or guardian’s signature


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