CENTRAL OREGON COMMUNITY COLLEGE in pdf form
Please bring completed waiver to first class
STUDENT NAME: ___________________________________________________
CLASS TITLE: ________________________________________ CRN: _________
The undersigned does hereby release and discharge CENTRAL OREGON COMMUNITY
COLLEGE (“COCC”), its employees, agents, officers, and directors for any and all claims, demands,
causes of action, damage, loss of services, costs and expenses in any way resulting from any and all
injury to person or property arising directly or indirectly out of the student’s participation in the above
activity, including any negligence on the part of COCC, its employees or agents.
Further, the undersigned agrees to indemnify and hold forever harmless COCC, its employees,
agents, officers and directors from any and all injuries, damages, costs, attorney’s fees whatsoever which
may arise out of the student’s participation in the above activity, including any negligence on the part of
COCC, its employees or agents.
The undersigned further consents and authorizes the representatives of COCC on the undersigned
behalf to obtain any necessary medical treatment or hospitalization or such other care necessary for the
health and welfare of the named student, and the undersigned agrees to be responsible for and pay the
costs of such medical treatment or hospitalization.
This release of liability and indemnification agreement shall be binding on the
heirs, successors and personal representatives of the student and the undersigned.
I have read the foregoing release of liability and the indemnification agreement and acknowledge
that the provisions are contractual and not a mere recital, and I understand I am bound by the terms hereof
by placing my signature hereon.
Date:
Student Signature
(If the student is under the age of 18, a parent/guardian must also sign below to consent and
grant permission for named student to participate in the above listed activity.)
_______________________________ Date: ______________________________
Parent/Guardian Signature
CE-Consent & Liability Waiver-5.03