Excursion Liability Release And Agreement Page 2

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MIRACOSTA COMMUNITY COLLEGE DISTRICT
EXCURSION LIABILITY RELEASE and AGREEMENT
Class: ___________________________________ Semester/Year: __________ Event Date(s):______________________
Instructor/Staff Member: _______________________________________ Mail Station #:________Phone Ext: __________
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 contents, ramifications and my responsibilities thereof as evidenced by me having signed below.
I am 18 years of age or older and am the Participant. If Participant is under 18 years of age, a Form
B-169M
must be completed
and signed.
Participant’s Printed Name
Participant/Parent/Guardian Signature
Date
______________________________________________________________________________
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INSTRUCTIONS
1. At the beginning of class, all students sign the form B-169 or parent/guardian for minor
students signs B-169M and the instructor retains the original.
2. When a field trip is arranged, the instructor completes the first event information and
date and has the VP IS or Dean sign
3. As the semester processes, the instructor obtains written approval by e-mail from the
Dean for the next specific event and adds it to the sheet.
4. Should a new student be added to the class, that signature will need to be included.
5. At the end of the semester, the final completed Form B-169 or B-169M is sent over to
RM at MS14 for filing.
6.
Overnight field trips should have the student complete the voluntary Participant’s Information
Sheet.
Form B-169 Class 09/14/2010
2

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