Waiver Of Liability printable pdf download

WAIVER OF LIABILITY / PERMISSION / MEDICAL RELEASE FORM

This form is necessary for any student staying overnight in a Mount Holyoke College residence. Please

complete the Waiver of Liability and Statement of Student Responsibility sections of this document and

fax them to the Office of Admission at (413) 538-2409 as soon as possible.

Name of Student _________________________________________________ Date of Birth _______________________________

Student Phone: Home____________________________________________ Cell_________________________________________

Home Address ____________________________________City ___________________________________State_____Zip________

Please let us know if you have any special needs (e.g. vegetarian, allergies, accessibility, etc) of which we should be aware.

___________________________________________________________________________________________________________

Name of Parent/Guardian ______________________________________________________________________________________

Parent Phone:

Home____________________________________________ Cell_________________________________________

Where can parent/guardian be reached while you are at Mount Holyoke (if different from above)?

___________________________________________________________________________________________________________

Please read Waiver of Liability and sign.

I hereby release, indemnify and hold harmless Mount Holyoke College, including Mount Holyoke College, its trustees,

employees, volunteer workers, students, agents and assigns from any and all liability, damage, claim of any nature

whatsoever arising out of or in any way related to my/my child’s participating including any and all travel risks in this

visit to Mount Holyoke. Participating in any activity is an acceptance of some risk of injury. I agree that my/my

daughter’s safety is primarily dependent upon my/her taking proper care of myself/herself. Despite precautions, accidents

and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participation in this

visit. Therefore, I assume all risks related to the activities. In case of an emergency and if my parent/we cannot be reached,

I do hereby authorize a representative of Mount Holyoke College to consent to any medical treatment or care deemed

advisable.

My signature below indicates that I have read, understood and freely signed this agreement, which shall take effect as a

sealed instrument. I expressly agree that this agreement shall be construed and enforced in accordance with Massachusetts

laws, and I consent to the jurisdiction of said state. I agree that this waiver and release is intended to be as broad and

inclusive as permitted under Massachusetts laws so that if any portion hereof is held invalid, the balance shall continue in

full legal force and effect.

Parent/Guardian Section:

I give permission for my daughter, the student participant named above, to visit Mount Holyoke College from

_____________________ (date of arrival) to _________________ (date of departure).

___________________________________________ ________________________________

Signature of Parent/Guardian

Date

_________________________________________ _______________________________

Signature of Student

Date

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Waiver Of Liability