Collin County Community College District
Out of State Program
Agreement - Waiver Form
Name:
_______________________________________________________
Program:
1. We understand that participation in this
program is entirely voluntary and that any program of travel involves some
element of risk. We agree that in
partial consideration of the College’s sponsoring this activity and permitting
the student to participate, we will not hold Collin County Community College
District, its Trustees, officers, agents or employees liable in damages for
injury or loss to person or property the student might sustain while so
participating; and we hereby release the College, its Trustees, officers,
agents and employees from any liability whatsoever for any personal injury or
property damage incident to participation in this program.
2. We understand the College reserves the
right to make cancellations, changes or substitutions in cases of emergency or
changed conditions in the interest of the group and that the program fees may
be subject to change. Should the College
cancel this program, full refunds will be made unless the cancellation is due
to political, natural, technological or other catastrophes beyond its control.
We understand that if the student leaves this
program for any reason, program fees will be refunded only according to the Payments
and Deposits section of this application form. In any case, the College can refund only
uncommitted, recoverable funds.
To prevent the loss of personal funds in this manner, the student may
wish to purchase trip cancellation insurance, when available, from an insurance
company or travel agent.
3. The student, as a participant in an out of
state study program, is a representative of the Collin County Community College
District and of
We understand that participation in this
program is considered a privilege, is subject to instructor’s approval, and
that the supervisor of this program reserves the right to require the student’s
withdrawal from the program at any time following the date of this application
for any reason, including deportment and character.
Each student enrolled in the New York Theatre
Field Studies Program is required to attend a mandatory travel workshop offered by the
office of Student Life. Details regarding
this workshop may be acquired by contacting Brad Baker, Chair of Theatre.
4. We understand that the College requires that all students be covered by appropriate sickness and accident insurance and that they be financially responsible for all medical expenses. In addition, we understand that payment for medical expenses customarily will have to be advanced and reimbursement sought later from the insurance carrier.
Further, this document certifies that, during
the time out of state, _________________________ (name of student/participant)
is insured with the ______________________________ (company) under Policy
Number ___________________________________, for sickness and accident
insurance. A copy of this insurance
policy or medical ID card will be made available to the coordinator of the New
York Theatre Field Studies Program for use in medical emergencies while out of
state.
5. We agree that the College cannot be held
responsible in any way for the safety, needs or well-being of any student when
he or she is not directly participating in program activities and under the
direct supervision of College personnel.
6. We grant to the Collin County Community
College District, or to any of its representatives, full authority to take any
action deemed necessary to protect the student’s health and safety at my
expense to include, but not limited to, placing the student under the care of a
doctor in a hospital at any place for medical examination and/or treatment, or
transport the student home at the student’s expense if such return is deemed
necessary after consultation with medical authorities.
It is understood that this authorization is
given in advance of any specific diagnosis, treatment, or hospital care being
required, but it is given to provide authority and power on the part of the
College to give specific consent to the diagnosis, treatment (medical or
surgical) or hospital care which, in the best interest and judgment of a
licensed physician, is deemed advisable.
Signature of student or participant:
__________________________________ Date: __________
Signature of parent/legal guardian:
__________________________________ Date: __________
(if
student/participant is under 18)
Contact information for parent, guardian, spouse or nearest relative
Name: _______________________________ Relationship: ____________________________
Address: ______________________________________________________________________
City, State, Zip:
________________________________________________________________
Telephone(s): __________________________________________________________________
(Home) (Cell)
Email: ________________________________________________________________________
Mail your completed and signed application and waiver to:
Professor Brad Baker, Collin Theatre, 2800 E. Spring Creek Pkwy, Plano, Texas 75074.
Or, FAX the completed forms to: Brad Baker, c/o Theatre @ 972 881-5103.