INFORMED ACKNOWLEDGEMENT OF HAZARDS AND RISKS CONNECTED WITH PARTICIPATION IN ACTIVITY Please Read Carefully and Be Sure You Understand Before You Sign
WARNING Participation in this Service Learning project, Campus Community Farm may involve injury or risk of some type to either yourself or others. Such risk or injury can include, but is not limited to, falls or trips; slips; sprains; fractures; bruises; scratches, tears, or other damages to clothing or personal possessions; dizziness; fatigue; shortness of breath; pain; and interaction with other participants. Any injury can impair one’s general physical and mental health and hinder one’s future ability to earn a living, to engage in other business, social and recreational activities, and generally to enjoy life. It could mean that you could die or become paralyzed. Paralysis means you will not ever again be able to move the part of you that is paralyzed. The purpose of this WARNING is to bring your attention to the existence of potential dangers associated with your participation in this activity. There is, however, always the risk of other types of injuries or the risk of injury or death resulting from other causes not specified here. The purpose of this WARNING is also to aid you in making an informed decision as to whether you should participate in this activity and, as a condition of such participation, sign the following: ACKNOWLEDGEMENT OF HAZARDS AND RISKS CONNECTED WITH SUCH PARTICIPATION. In addition, its purpose is to make you aware that it is your responsibility to be very alert as to matters of your personal safety and to require you to learn as much as possible from and ask questions of the Center for Service-Learning Program Manager/Coordinator/Programmer that you might have at any time regarding your safety and well-being and the safety of the activity. You must inform those faculty/instructors/facilitators who are in charge of this activity of any personal relevant existing medical condition you may have, [and obtain the permission of your personal physician before you can undertake this activity (only if the activity involved any strenuous activity such as having to walk long distances, hike, climb rocks, etc.).] It is your responsibility to dress appropriately for participation in the activity. You represent and warrant that you are physically fit and able to participate in this activity. It is also your responsibility to use all safety equipment and gear provided by or recommended by the Center for Service-Learning Program Manager/Coordinator/Programmer and follows all instructions given to you before, during, and after the activity.
-2ACKNOWLEDGEMENT OF HAZARDS AND RISKS I, ________________________________________________ (Name) want to participate in the (Print Name and MI)
Service-Learning project of Campus Community Farm at Edmonds Community College. I have read the attached WARNING, and I understand that this is an activity involving the POSSIBLE RISKS OF INJURY, PARALYSIS, OR DEATH. I also understand that by participating in such an activity/class/program at Edmonds Community College, I am subject to the possibility of injury, paralysis, or death as outlined in the WARNING attached. By signing this Acknowledgement of Hazards and Risks, I acknowledge that: 1.
I have read and understand its contents and agree to its terms.
I have had a chance to ask questions and seek advice.
I have informed the Center for Service-Learning Program Manager/Coordinator/Programmer in charge of this activity of all of my existing relevant physical and emotional conditions.
My parent(s) hereby make these promises on my behalf.
I voluntarily choose to participate in the service learning project listed above at Edmonds Community College.
Check One: I am under age 18 ______ (Custodial Parent Signature Required)
____________________________________________ (Signature of custodial parent)
____________________________________________ College Position/Title