Fillable Printable Release of Liability Form-Memorandum

Release of Liability Form-Memorandum

STETSON UNIVERSITY

TRAVEL and TRIP RISK ACKNOWLEDGEMENT/LIABILITY WAIVER FORM

– FOR STETSON FIELD TRIPS, OFF-CAMPUS FUNCTIONS OR COURSE RELATED TRIPS AND RECREATIONAL ACTIVITIES

Stetson University sponsors field trips and special events for students as a means of providing a comprehensive and diverse learning environment. Field

trip/event participants and leaders are expected to conduct themselves in a professional and positive manner as representatives of Stetson University. All

students must adhere to and are responsible for knowing the Student Code of Conduct as part of their enrollment at Stetson University. Failure to follow

operating guidelines, instructor/staff directives, and the Student Code of Conduct may result in disciplinary action. (Student Code of Conduct is now available

on the Stetson Intranet under the “Res Life” section / ‘Policies’/ `Code of Community Standards’).

I. TRAVEL: Trip Director and Dept:

Name of Field Trip, Course & Travel Dates: (Date (s)- Trip to : (Name of Venue/Bldg/Org) in (City, State); Course:

(“trip”)

Mode of Travel: ___ Self-Travel/Personal Vehicle ____Rental Vehicle ____ Commercial Bus/Shuttle

Special Activities/ Risks include but are not limited to: Vehicle Travel to ‘ City, State’; Foot Travel at location, Exposure to

unfamiliar city or large crowds, Exposure to weather or outdoors, etc

Precautions : Check weather before departure; Wear appropriate clothing for venue and proper footwear for walking/activities.

Additional Risks, Activities and Precautions including Overnight Stay: - Please see the attached as applicable!

This is to certify that _______________________________________ has full permission to, and/or has voluntarily agreed to:

(Student / Participant Name - Print)

Travel in a group or independently, off campus, within the United States, in connection with a field trip, function, event, or course of

Stetson University, Inc. (“university”).

II. LIABILITY WAIVER / RISK ACKNOWLEDGEMENT:

I understand that participation in trip activities could involve risk of physical injury, illness, death or property loss, and despite safety

precautions, the university cannot guarantee safety thereof, as all risks cannot be prevented. Stetson University, does not provide health and

accident insurance for trip participants, and I understand that any medical expenses, property loss, or other personal expenditures that result

during or from this travel/trip, are to be borne by the student/participant, or by their parent or guardian (if student/participant is a minor). I also

hereby consent, give authorization to, and release from liability; trip leaders to secure any emergency medical treatment in event I am unable

to, and I agree to be responsible for the costs thereof.

I further acknowledge that if I drive my own vehicle, or am a passenger in another’s private vehicle in connection

with this trip/function, that Stetson University’s auto insurance does not cover such a private vehicle. I also understand that the University

cannot be responsible for assuring the safety and reliability of such private transportation or driver, nor for any

non-sponsored activities and travel that I/my child might choose to participate in before, during or after the university sponsored function, and I

therefore accept the risks and responsibilities associated with such private vehicle travel and activities.

In consideration of the opportunity afforded, with full knowledge and acceptance of the risks associated with this trip and any

recreational activities noted within; and with full understanding of the above issues/conditions and risks, I hereby release, indemnify

and hold harmless Stetson University, Inc, its faculty/staff, trustees, officers, volunteers, and agents from all form and manner of risks

inherent in, and from all claims, suits and demands of any nature arising from participation in said trip, or activities.

__________________________________________________________ __________ ________________________________________________________________

Signature of Student/Participant Date Signature of Parent or Guardian Date

(needed if student/participant is a minor – under 18 )

_____________________________________________________________ ___________________________________________________________

Print Student/Participant Name Print Parent/Guardian Name

_____________________________________________________________ ___________________________________________________________

Signature of Witness for Student/Participant Signature of Witness for Parent/Guardian

Emergency Contact Name:________________________________________ Phone:________________________________ (Rev- 1-14)

ADDITIONAL TRIP INFORMATION REGARDING TRAVEL, TRIP ACTIVITIES

AREA CONDITIONS and ADDITIONAL RISKS AND PRECAUTIONS

NAME OF TRIP, Function and/or Course:

DATE(S) OF TRIP:

MODES OF TRAVEL included in Program/Activity: (Check ALL that apply)

Bus__ Van/shuttle__ University Rental__ Personal Vehicles__ Plane__ Train__ Water vessel__

Extensive Foot Travel/Walking/Hiking___

Note: If this box is checked, participants will be responsible for their own travel to and from the trip

destination.

Trip Includes Overnight Stay : Yes_____ No_____

Recommended Precautions for Overnight Stay:

 Check local weather before departure

 Bring appropriate clothing, footwear etc suitable for destination weather, standing/walking and activities

 Use buddy system and regular contact during non-university related activities and at night. Do not venture out

alone at night

 Do not give out personal info or hotel room info to strangers - Do not go anywhere with strangers and do not

let strangers into your hotel room except for appropriate hotel staff as necessary. Keep room door closed and

locked. Check hotel room peep-hole before opening room door.

 Keep within safe boundaries of hotel/city (Concierge of hotel can advise)

 Note where all fire exits are in hotel

 Avoid bringing valuables. Stetson University is not responsible for lost or stolen items.

 Bring any necessary medications or emergency/medical kits (ie bee sting kits/epi-pen, inhalers, etc)

 Know how to reach your trip leader in event of an emergency or issue

 Note Stetson Public Safety 24 Hour Hotline in your Cell Phone: 386-822-7300

Location and Special Conditions:

Type of Accommodations: Hotel:___ Campground___ Other:____ (explain):

Name and phone number of Hotel or Campground:

IF TRIP INCLUDES RECREATIONAL ACTIVITIES OR SPECIAL RISK ACTIVITIES, PLEASE SEE

ATTACHED!

I have thoroughly read and understand the preceding and forgoing information, to include any

special risk or recreational risks included with this trip/travel as noted herein.

I understand that all recreational activities are completely voluntary and based upon my own

decision and I acknowledge that I may choose to decline these activities at any time. I hereby

accept the associated risks and understand the precautions thereof.

Participant Signature: ______________________________________________________________Date:________________

Parent/Guardian Signature: _________________________________________________________ Date: ________________

Optional (for Participant):

Additional Information or Instruction for Emergency purposes:

Participant Special Needs Request:

RECREATIONAL OR SPECIAL RISK ACTIVITIES

RISKS AND PRECAUTIONS

Trip Leaders: Please check ALL that apply to this Trip/Function:

CONTACT SPORTS (Football(any type), Soccer, Lacrosse, Boxing, Wrestling)

NON-CONTACT SPORTS (sports not included in above)

Please List All that Apply:

RECREATIONAL ACTIVITIES (NOT-Water related) - Please Circle ALL that Apply:

Theme Park Activities, Carnival/Fair Rides, Inflatable Rides/activities, Camping, Hiking, Zip-lining, Horseback riding, Ropes

course, Archery, Climbing wall, Skeet shooting/gun range, Fencing, Bowling, Badminton, Wall Propelling, ATV or Go-cart

riding, Mini-Golf Park activities, Petting Zoo/Animal interaction, Theatre/Performance activities. Other (Please Explain):

RECREATIONAL WATER-RELATED ACTIVITIES – Please Circle ALL that Apply:

Swimming, Snorkeling/Diving, Canoeing/Kayaking, Fishing, Surfing, Beach activities, Wind surfing, Sailing, White-Water

Rafting. Other: (Please Explain):

VOLUNTEER/SERVICE-PROVIDING ACTIVITIES: (Please circle ALL that apply):

Gardening/farm/crop activities, Assistance with Building Projects, Computer projects, Tutoring/mentoring,

Other: (please explain):

Other Special Risk Activities: Please Describe:

Possible Risks or Injuries included in the above activities may include, but are not limited to:

Risk of injury inherent in playing any type of sports or recreational activities; Exposure to outdoors, nature, weather, Acts of

God, sea life, insects/animal or plant life; Inexperience or unfamiliarity with the activity or its requirements; Unfamiliarity with

location or facility; Faulty equipment/gear or inadequate instruction, Violence/criminal acts of others; Complications or reaction

from weather conditions or outside environment or Nature; Inadequate or unavailable healthcare facilities or assistance;

Accidents; Illnesses; Allergic Reactions(food, plants, insects etc); Negligence; and/or Mistake.

I understand and acknowledge that these risks may result in personal injury, including but not limited to the following:

Collision with: other players/participants, sports/recreational equipment, structures, vehicles, swimmers, vessels or surfers;

Slips/trips/falls; falls from heights, fractures/broken bones; sprains/strains; bruises; lacerations; punctures; concussion; loss of

consciousness; physical exhaustion/heat exhaustion; hypothermia, eye injuries; sunburn/windburn/camping burns; drowning;

diving/boating accidents; bites/stings/burns/rashes from contact with animals/insects or sea life; sun poisoning or stroke; injuries

from shark attack; spinal injuries; paralysis; brain damage; serious injury to internal organs, bones, ligaments, joints, muscles,

tendons, and other aspects of the muscular skeletal system; neck, face and head injuries; ear injuries, heart attack; sickness;

and/or death as a result of the nature of some related activities. Possible loss or damage to personal property; Etc.

Recommended Precautions :

 Check local weather before departure and become familiar with recreational activities you plan to do

 Bring appropriate clothing, footwear, supplies, protective gear (sports related, sunglasses, sunscreen, hat, etc) suitable

for destination weather, outdoor or recreational activities, standing/walking etc.

 Avoid bringing valuables or keep secure at all times. Stetson University is not responsible for lost or stolen items.

 Bring any necessary medications or emergency/medical kits (ie bee sting kits/epi-pen, inhalers, etc)

 Know how to reach your trip leader in event of an emergency or issue

 Note Stetson Public Safety 24 Hour Hotline in your Cell Phone: 386-822-7300