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RELEASE AGREEMENT AND EMERGENCY INFORMATION FORM

SONOMA STATE UNIVERSITY

 

Title of Event ________________________________________________________________

Date(s) of Event ______________________________________

I. PERSONAL INFORMATION

Student Name ________________________________________________________________

Birth Date ____________________________

SS# _______________________________

Home Address _________________________________

Telephone _____________________

II. MEDICAL CONDITIONS

Students with medical conditions, allergies, or disabling conditions must be accommodated for all field trips and off-campus class activities. This includes finding alternative activities to learn the same information. Faculty will provide, in advance, specific information to students regarding the type and rigors of the trip/class activity (e.g., miles to be covered, elevation change, terrain, etc.). Students are then responsible for identifying the need for modifications or alternative activities. The Disability Resource Center is available for suggestions and assistance in negotiating adaptations.

Medical Conditions ___________________________________________________________

Allergies ____________________________________________________________________

Medications _________________________________________________________________

III. INSURANCE COVERAGE

It is important that both students and supervising faculty, staff members, and administrators be aware of their respective responsibilities to exercise due care in planning for, and participating in, field trips, other off-campus class activities, and other off-campus events, including adequate preparation for medical emergencies that may arise. Students having no health insurance may encounter financial liabilities if they require ambulance and/or other medical services as a result of sickness or injury occurring during field trips or other off-campus class activities. Sonoma State University and the State of California do not provide coverage for the medical costs incurred by students. The CSU system maintains a very limited "injury only" policy for enrolled students participating in school-sponsored activities away from campus.

Do you have health insurance coverage from your employer, and/or through a parent/s, a spouse, or domestic partner? ________________ If yes please indicate below.

Your Policy: Company ___________________________________________________

Policy Number _____________________ Primary Insured ______________________

Company Address ________________________________ Telephone _______________

IV. EMERGENCY CONSENT and NOTIFICATION CONTACT

In the event of an emergency I hereby authorize Sonoma State University representatives to take necessary emergency measures for my safety / protection and to contact the following individual to notify them of my condition.

Name _______________________________________________________________________

Address _____________________________________________________________________

Home Telephone _____________________ Work Telephone ______________________

This form must be completed prior to the field trip or off-campus event. One copy of the form is to be retained by the supervising faculty, staff or administrator for use during the field trip or off-campus event. One copy will be filed in the appropriate department office.

In order to be permitted to participate in an off-campus event, the participants need to agree to the following terms under which they will agree not to hold the University and its related organizations financially responsible for any injury or damage they may sustain. *

V. RELEASE AND INDEMNITY

I, ________________________________________, in consideration for being

(print full name)

permitted to participate in an off-campus activity, agree to hold harmless, defend, and indemnify the State of California, the trustees of the California State University, Sonoma State University and its auxiliary organizations (e.g., Sonoma State Enterprises, Inc., Sonoma State University Academic Foundation, Inc., Associated Students of Sonoma State University, and Sonoma Student Union Corporation) and the officers, employees, and agents of each of them, from any and all loss, damage, and liability which I may incur or which may occur in connection with the off-campus university event in which I am being permitted to participate. I agree to these terms freely and understand that I may have this language reviewed by a counsel or advisor.

Executed this _____ day of ___________________, _______ in Sonoma County, California:

By:__________________________________________________

(signature of participant)

If participant is a minor the approval and signature of the participant's parent or legal guardian is required:

As Parent/Legal Guardian of the participant, I ___________________________________, agree to the terms of the release and indemnity stated above.

Executed in _______________________ County, State of California, on this

______ day of _______________________, ______.

By:___________________________________________________

(Signature of Parent/Legal Guardian)

* This form is not for employees of the university who are participating in an off-campus event as part of their job responsibilities.

NOTICE OF PLANNED OFF-CAMPUS EVENT

1. Title / Description of Event:

 

 

2. Beginning Date & Time:

 

3. Ending Date & Time:

 

4. Location/s of Event:

 

5. Participants:

  1. How Many:
  2. Group / Class / Reason For Participation (e.g., Physics 100 students, members of the Ski Club, etc.):
  3. Guests - Please Name:
  4. Volunteer Employees - Please Name:

 

6. Will Alcoholic Beverages be Provided?

_____ Yes _____ No

7. Sponsoring Faculty, Staff, or Administrator:

Name:

 

Department or Division:

 

Please file the completed form with your Department Chair and School Dean or Vice President, as appropriate.


Related Links: Back to Affirmative Action and Non-Discrimination Policy

Updated November 3, 2000 by UAO.WebContact@sonoma.edu