Assumption of risk form

Virginia Peninsula Community College

INTERCOLLEGIATE ATHLETIC ASSUMPTION OF THE RISK FORM

            I agree that as a participant in the ________________athletic program at Virginia Peninsula Community College, I am responsible for my own behavior and well-being.  I acknowledge that I have been informed of the general nature of the ______________athletic program, and I understand that it may involve risks to my personal safety.  Unless otherwise rescheduled, this program's activities will begin on or about -___________(date/semester/season) and end ___________ (date/semester/season). 

            Participation in this athletic program may contribute to, or result in, the loss of, or damage to, personal equipment and accidental injury, illness, or in extreme cases, personal trauma or death.  Risks during participation in this program include, but are not limited to, getting hit and/or hurt by teammates and other participants in practices and games, getting cut and bruised, tearing ligaments, breaking bones, and experiencing head injury or trauma.

I understand that in the event of accident or injury personal judgment may be required by program personnel regarding what actions should or must be taken on my behalf.  Nevertheless, I acknowledge that the College personnel may not legally owe me a duty to take any action on my behalf.  I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition.

            I further agree to abide by any and all the College’s rules applicable to this athletic program; and, I will take responsibility for abiding by specific requests made of me for my safety, the safety of others, or the welfare of any general interests concerning the athletic program.  I understand that the College reserves the right to exclude my participation in this athletic program if at any time my participation or behavior is deemed detrimental to the safety and welfare of others.

            Therefore, in consideration for being permitted to participate in this activity on my own initiative, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of, my property which may occur as a result of my participation in this activity or arising out of my participation in this activity, unless any such personal injury, damage to or loss of my property is directly due to the negligence of the College.  I understand that this Assumption of Risk form will remain in effect during my participation in this athletic program, unless a specific revocation of this document is filed in writing with the (Athletic Director/other College administrator), at which time my participation in this athletic program will cease.

            I acknowledge that I have read and fully understand this document.  I further acknowledge that I am accepting these personal risks and conditions of my own free will.

            In case an emergency situation arises, please contact _______ _____________ (name) at __________________ (phone number).

_____ I represent that I am 18 years of age or older and legally capable of entering into this agreement.

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                 Participant’s signature

        Date

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Street Address             City                 Zip

If participant is less than 18 years of age, the following section must be completed:

_____ My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this program and agree to be responsible for his/her behavior during his/her participation in this program.

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            Child’s Name

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Address

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Parent’s or guardian’s signature

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        Date