Assumption of Risk, Agreement to Abide by
Code of Conduct, Release of Liability, and
Limited Medical Authorization
Assumption of Risk, Waiver of Liability, and Medical Authorization
I recognize that participation in learning activities involves certain risks to my property and person that, in rare
circumstances, can be serious or even lethal. In particular, I understand that the College activity will involve the following
activities.
Date of Activity:
Destination:
Purpose of Activity:
I freely assume those risks associated with these activities. I further understand and agree that Southern Regional
Technical College (SRTC) shall not assume any liability for damage to or loss of my property or for financial obligations
incurred by me. I also agree to give up any rights I may otherwise have to sue or otherwise bring claims against Southern
Regional Technical College and its officers, faculty, employees, or agents, for personal injuries or death or other harm,
except for those injuries, death, or other harm caused by a deliberate wrongful act of the aforementioned Technical
College and/or its officers, faculty, employees, or agents. I understand that it is possible for me to purchase insurance, at
my own expense, that will indemnify me against the risk of the financial losses outlined in this paragraph.
Code of Conduct: I hereby agree that in consideration of my being permitted to participate in this Southern Regional
Technical College activity I will be subject to the supervision and authority of the faculty and/or advisor in charge. I also
understand and agree that the faculty and/or advisor in charge has the sole authority to make decisions regarding my
continued participation in the activity if they determine that my conduct warrants disciplinary action or if they determine
that my continued participation, for whatever reason, poses an immediate risk of harm to me or to others. I will abide by
the College’s Code of Conduct as published in its Catalog/Handbook.
Medical Emergency: In the event of an emergency and I am unable to act on my own behalf, I authorize the faculty and
advisors of the College activity to take whatever action they deem is warranted and appropriate regarding my health and
safety.
Declaration and Release of Parent or Guardian for Participants Who are Under 18 Years of Age:
I certify that I am the parent or legal guardian of the student named below who has applied for participation in the College
activity. I have read the forgoing Assumption of Risk, Waiver of Liability, and Medical Authorization, and I understand it.
Further, in consideration of my child being permitted to participate in the above mentioned college activity, I accept and
agree to be bound by, on my own behalf and on behalf of my child, the terms and conditions set forth in the foregoing
Assumption of Risk, Waiver of Liability, and Medical Authorization.
I hereby certify that I am ________ years of age (under 18 must be approved by parent or guardian) and have read the
above carefully before signing. I further acknowledge and agree to abide by the student Code of Conduct and will also
abide by the information found on the reverse side of this form.
In WITNESS WHEREOF, I have hereunto set my hand and seal this
Parent/Guardian
Signed, Sealed, and
________________.
day of
Print Participant Name
Delivered
in
the
Presence
of:
, 20
Participant Signature
___________________________________,
date
NOTARY PUBLIC
My Commission Expires ___________________________________
(note: all blanks front and back must be filled)
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SRTC STUDENT ORGANIZATION BEHAVIOR GUIDE
College activities are considered to be a part of Southern Regional Technical College’s (SRTC) instructional program
whether they occur during regular program hours on campus or after school hours on the campus or at some other
location. Therefore, the College Code of Conduct applies to all organized college activities regardless of time or place.
College students who are participating in college activities must understand that these activities are an extension of
SRTC’s instructional program and govern themselves accordingly.
It is the responsibility of program chairs and directors, college staff, student organization advisors and chaperons to inform
their students that leadership conferences, competitive events, and other student organization activities are part of
SRTC’s instructional program and that students are to follow regular school conduct when participating in these activities.
Students who fail to follow the College Code of Conduct will be sent home immediately from any college activity occurring
away from campus at their own expense and will be subject to appropriate disciplinary actions by the SRTC administrative
personnel.
ACKNOWLEDGEMENT
I understand that all college activities sponsored by SRTC require me to abide by the College’s code of conduct at all
times. I further agree to abide by the following guidelines (please initial each line):
Students shall keep their faculty member informed of their whereabouts at all times.
Curfew each night will be designated on the program or announced by the faculty member and all students
will be in their rooms by curfew.
Males will not be in females’ rooms and/or females shall not be in males’ rooms at any time unless a faculty
member is present.
No alcoholic beverages or illegal drugs shall be possessed or used by anyone on the College activity at any
time under any circumstances.
Students shall attend all general sessions and activities assigned for which they registered unless engaged in
some other authorized activity or excused by the faculty member.
Students should participate in the transportation services being provided by the College. Under extraordinary
situations, a student may use his/her own personal vehicle (if properly insured and licensed – attach copies).
Students and faculty are not to transport other students in their personal vehicles.
Students understand that they may be sent home at their own expense for not following the College’s code of
conduct.
Students shall abide by activity rules in a manner that will bring pride to their student organization and their
College.
EMERGENCY CONTACT INFORMATION
In case of an Emergency, please notify the following individual(s):
NAME OF CONTACT
CONTACT NUMBER
Adopted 7-1-2015
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