Student Organization Trip Waiver
Student Expectations and Acknowledgement of Risk and Release (Please read carefully)
First and Last Name
Trip Location (City, State and Country)
Trip Start and End Date
My electronic signature below signifies that I understand the following expectations, policies, and procedures, and that I agree to abide by them. 1) I am responsible for my own actions at all times. This includes, but is not limited to: a) Transporting, checking, and reclaiming my own luggage, and may be limited to the amount of luggage I can carry unaided with reasonable speed and confidence. I am responsible for my own private possessions during the entirety of the trip. b) Abiding by all the rules and regulations of Cornell College, and observing the laws and customs of the households and communities of the region or country in which the trip takes place. c) If I consume alcohol, I am expected to do so legally and with the moderation characteristic of the most responsible of adults, demonstrating consideration for myself and others. 2) There will be absolutely no possession or use of illegal substances of any kind, including marijuana. 3) I certify that I am physically, mentally, and emotionally capable of participating in the activities of the trip. 4) I certify that I have the necessary quantity of all medication needed for the duration of the trip and assume responsibility for taking said medication.
Please list any allergies
Please list any regularly taken medications
Please list any other health conditions
5) I certify that I am covered by the following medical insurance plan and will be covered for the duration of the trip. I recognize that Cornell College does not have an obligation to provide me with insurance.
Name of Hospitalization Plan
Insurance Card Number
In case of an emergency, I grant Cornell permission to contact the following individual(s) and discuss any medical or personal situation I may have encountered during the trip:
Name and Relationship
City, State, Zip
Phone Numbers (home, work and cell)
6) I accept the responsibility to pay for any medical treatment I may need before, during, and following the trip, including but not limited to: visits and treatments my physician may suggest prior to and following travel, vaccinations, medications, incidental and emergency treatment. 7) It is understood that when I travel outside of the organization planned trip, such travel is done at my risk alone, and that Cornell College does not assume any responsibility for what transpires as a student travels on her/his own. 8) I understand that if I use my personal vehicle or a rental vehicle for the benefit of the organization, Cornell College has no liability for injury or property damage which may result from that use. I agree to rely solely on my personal vehicle insurance coverage. 9) I acknowledge that the activities involve exposure to various risks (including but not limited to vehicle accidents, illness, etc.). 10) I acknowledge that the on-site coordinators are not representatives or agents of Cornell College and as such the college has no liability for their actions, performance, omissions or requests. 11) I acknowledge that any lodging providers are not representatives or agents of Cornell College and as such the college has no liability for their actions, performance, omissions or requests. 12) I acknowledge that all transportation providers are engaged as independent contractors and not as agents or employees of Cornell College. In addition, I acknowledge that Cornell College, the faculty and staff shall not be liable for participants who choose to travel independently of or extend travel beyond that of the arranged trip. 13) I understand that a credit card or cash may be the only way to receive medical care in a certain areas of the country. 14) I acknowledge that Cornell College and the faculty and staff shall not be liable for any theft, loss, inconvenience, damage, or injury to applicant or his/her property occasioned by, or arising from, any defective equipment or any act, omission, negligence or breach of duty of fellow students, hotels, or similar institutions, carriers (public or private), restaurateurs, travel agencies, purveyors, or any agent of servant of them, or any person of company engaged by Cornell College or from any changes in transportation service, sickness, weather, strikes, war, quarantine or other cause. 15) I assume all risk and financial responsibility for any loss or injury to myself that may result from my actions or omissions, including, but not limited to, any undisclosed physical or emotional problems that might impair my ability to complete the trip, and I release Cornell College from any liability for injury to myself or damage to or loss of my possessions.
Waiver of Liability
In consideration of being permitted to participate in and travel to the above-named location sponsored by the above-named organization, I hereby release, discharge and agree to hold harmless Cornell (including but not limited to Cornell’s Student Activities Department), Cornell’s trustees, officers, faculty members, employees, agents, advisors or any one or more of them, or their executors, administrators, heirs or assigns (the “Released Parties”) from any and all claims, demands, damages, costs, expenses, actions and causes of action, present or future, on account of injuries to my person or property caused in whole or in part by the active or passive negligence of the Released Parties, arising out of or in connection with my participation or transportation the above-stated trip. I intend for this release and indemnity agreement to protect the Released Parties from any and all claims, demands, damages, costs, expenses, actions and causes of action, present or future, of my executors, personal representatives, heirs and assigns, or any other person or entity, on account of injuries to my person or property, including injuries resulting in my death. I also recognize and agree that the Released Parties assume no responsibility for any liability, damage, or injury that I might sustain due to the intentional or negligent acts or omissions of any other person participating in or traveling to the above-named trip.
Indemnification and Hold Harmless
In further consideration of my being permitted to participate in and travel to the above-stated trip, I, for myself and for my executors, personal representatives, heirs and assigns, hereby assume full responsibility for the risks, foreseen or unforeseen, of property damage, injuries, or death to myself or to others arising out of my participation. I agree to indemnify and hold harmless the Released Parties from all claims, demands, damages, costs, expenses, actions and causes of action, present or future, including but not limited to costs of medical treatment and reasonable attorneys’ fees, that may accrue to any person or entity as a result of any property damage, injuries, or death, caused by me or arising out of my participation in or travel to the above-state trip.
I expressly agree that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Iowa and that if any of its provisions are held to be invalid, the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding
I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to bring legal action or assert a claim against Cornell. I acknowledge that by submitting this form, I am signing the agreement freely and voluntarily and affecting a complete and unconditional release of all liability to the greatest extent allowed by law. I understand that Cornell College reserves the right to make cancellations, changes or substitutions in case of emergency or changed conditions. I have read this Expectations and Acknowledgement of Risk and Release, understand its contents, and agree to abide by the terms of this agreement. I have had a chance to ask questions regarding this consent form and have had those questions answered to my satisfaction. I do hereby release, discharge and covenant not to sue Cornell College, its governing board, employees or agents as to any and all liability that may arise out of injury or harm to me, death, or property damage, resulting from my participation in this trip, excepting only liability due to the negligence or willful misconduct of the College.
Electronic Signature of Participant
Date of Birth
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