4.100 Form

Agreement to Participate

I __________________________________________hereby state that I am physically and mentally capable of safe participation in Seminole State College's Off Campus Activity listed below. I have been advised that the activities in the program may include, but are not limited to: transportation to and from the off campus site, instruction in or out of the classroom, field trips or outdoor activities. While few injuries ever occur, I am aware that participation could lead to injuries that may require first aid or emergency medical treatment. I understand that I am responsible for the costs of any medical treatment arising from participation in the program.

Off Campus Activity: _____________________________________________________

________________________________________________________________________

I acknowledge that as a participant in these activities it is my responsibility to abide by the rules and regulations applicable to the activity, to follow the directions of the activity supervisor and to help ensure the safe conduct of the activity for all concerned.

Release of Liability

________ I assume all risks and hazards incidental to the conduct of this program and hereby release Seminole State College from any claims for personal injury or property damage resulting from the negligent acts or omissions of Seminole State College, its faculty, staff, agents or employees.

Permission for Emergency Treatment

________ I hereby authorize Seminole State College to obtain emergency medical treatment for me in the event that I am unable to give consent to such treatment and in the event that my parent(s), relative(s), next of kin or emergency contact person(s) cannot be reached, in order to protect and preserve my health and well being.

________________________________________________________________________
Signature Date