Waiver And Release Of Liability Form (Page 2 of 2) in pdf

Complete this side only if under the age of 18.

BOARD OF TRUSTEES OF COMMUNITY-TECHNICAL COLLEGES

Three Rivers Community College

Parental Authorization and Waiver/Release of Liability

I,_____________________, parent or legal guardian of _____________________, a minor child, hereby give

permission for my child to participate in activities conducted by Three Rivers Community College in connection

with Service Learning courses.

I certify that my child is physically, mentally and emotionally able to participate in the activity described above. In

consideration of being permitted to participate in the activity, I hereby voluntarily release Three Rivers Community

College and the Board of Trustees for the Community-Technical Colleges from any and all liability resulting from

or arising out of my child’s participation. I understand and agree that I am releasing not only the entities set forth

above, but also the officers, agents, and employees of those entities. I understand and agree that this Waiver/Release

will have the effect of releasing, discharging, waiving, and forever relinquishing any and all actions or causes of

action that I or my child may have or have had, whether past, present or future, whether known or unknown, and

whether anticipated or unanticipated by me or my child, arising out of participation in the activity.

I understand and agree that by signing this Parental Authorization and Waiver/Release of Liability, I am assuming

full responsibility for any and all risk of death or personal injury or property damage suffered by me and/or my

minor child while participating in the activity. I understand and agree that by signing this Parental Authorization

and Waiver/Release of Liability, I am agreeing to release, indemnify, and hold harmless Three Rivers Community

College and the Board of Trustees for the Community-Technical Colleges and their officers, agents, and employees

from any and all liability or costs, including attorney fees, associated with or arising from participation in the

activity. I understand that this Waiver/Release of Liability will be binding on me, my spouse, my heirs, my personal

representatives, my assigns, my children, and any guardian ad litem for said children.

I acknowledge that I have read this Parental Authorization and Waiver/Release of Liability and that I understand the

words and language in it. I also understand that this Parental Authorization and Waiver/Release of Liability is valid

for the duration of time that my child participates in the activity unless rescinded through my written instructions.

I am the parent or legal guardian of the minor,______________________________, and I am signing this Parental

Authorization and Waiver/Release of Liability on behalf of said minor.

Student’s Home Address:___________________________________________________

Street Address

City

State

Zip Code

Home Phone #:_( )________________

Student's date of birth: ______/______/______

Student ID #:___________________________

Student's School:______________________________________ Grade level:_________

Print Student Name: __________________________________

Signature of Student (Age 7 or older): ___________________________

Print Name of Parent/Guardian: _________________________

Signature of Parent/Guardian: _____________________________ Date:_____________

Waiver And Release Of Liability Form Page 2