PLEASE COMPLETE AND RETURN TO STUDENT LIFE OFFICE
COMMUNITY COLLEGE OF ALLEGHENY COUNTY STUDENT AFFIRMATION AND RELEASES
READ CAREFULLY BEFORE SIGNING
I ___________________________________________ desire to take part in a student activities program offered by the Community College of Allegheny County (the “College”) and hereby affirm that I have been advised and thoroughly informed of the dangers and risks involved in my participation in the activity. By signing this “Affirmation and Release,” I ce rtify that I am cognizant of those risks and dangers. I understand and agree that neither the College, located in Allegheny County, Commonwealth of Pennsylvania, nor any employee or agent of the College may be held liable in any way for any occurrence in connection with this program which may result in harm, injury, death, or other damage to me, my family, estate, heirs, or assigns In consideration of being permitted to participate in this program, I hereby personally assume all risk in connection with the program for any harm, injury, death, or other damage which may befall me while I am participating in the program, including all risks connected therewith, whether foreseen or unforeseen; and further, to save and hold harmless the College and its employees and agents from any claim by me or my family, estate, heirs, or assigns arising out of my participating in this activity. I further affirm that I am of lawful age and legally competent to sign this “Affirmation and Release,” or that I have acquired from my parent(s) or guardian(s) his/her/their written consent, a copy of which is attached hereto. I understand the terms herein are contractual and not a mere recital, and that I have signed this document of my own free will. Student’s signature also gives the Community College of Allegheny County, and those acting under its permission or upon its authority, the right and permission to use photographic reproductions or likenesses taken for the purpose of advancing the College.
This authorization and release covers the use of said material in any published form and any medium of advertising or publicity for an unlimited period of time.
This agreement represents in full all the terms and considerations and no other documents, statements or promises have been made to me nor have I been offered or accepted any remuneration for my voluntary participation.
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THESE “AFFIRMATION AND RELEASES,” BY READING IT BEFORE SIGNING.
Name (print) __________________________________________________ Age ____________________________
Address ______________________________________________________________________________________
Phone ____________________________________________
Name of Activity/Campus _______________________________________________________________________
Date of Activity ____________________
Emergency Contact ___________________________________ Emergency Phone _________________________
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___________________________________________
SIGNATURE
DATE
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