Student Work-Based Learning Agreement, Waiver and Release

Student Name:        _____________________________________________

For students under 18 years old, this form must be initialled and signed by a legal guardian.

Waiver and Release:

In consideration of placement into the Pikes Peak Business & Education Alliance (PPBEA) work-based learning program, I (the above student) hereby waive, release and discharge any and all claims or damages for property, personal injury, or death, which may occur as a result of participation in a work-based learning experience.  This release is intended to discharge, in advance, PPBEA and my school district of enrollment of negligence or carelessness on the part of the student.  It is understood that this activity involves an element of risk and danger of accidents, and knowing those risks, I hereby assume those risks.  It is further agreed that this waiver, release and assumption of risk is binding.  I agree to indemnify and to hold PPBEA and my school district of enrollment free and harmless from any loss, liability, damage, cost, or expense, which they may incur as the result of my placement in a work-based learning or training experience.

Parent/Guardian Initials:        __________                Student Initials:        __________

Work-Based Learning Agreement:

I (the above student) understand and agree to the following.  Please check each box below.

Student Name:                ___________________________________        

School District Name:                ___________________________________

School Name:                        ___________________________________

Student Signature:                ___________________________________        Date:        __________

Parent/Guardian Name:        ___________________________________

Parent/Guardian Signature:        ___________________________________        Date:        __________

Insurance & Emergency Contact Information:

Student Name:  _______________________________________  

Date of Birth:  ____________________         Age:  ____________        Sex:  ________________


Address:  ____________________________________________  

City/State:  ___________________________________________         Zip:  _________________

Phone Number:  _______________________________________

Driver’s License #:  __________________________________  Issuing State:  ___________

Auto Insurance Company:  ____________________________________________________  

Auto Insurance Policy #:  __________________________________

Emergency Contact Name:  ________________________________________  

Relationship:  ______________________ Emergency Contact Phone:  ___________________

List any health conditions that may limit student’s work efforts or that may require special attention.  Also, detail actions required by others to respond to listed conditions: