Procedure No. 212.1, Supplement 1

Area: Student Affairs

Revised: 8/3/10


Name of Club_______________________________________________________________

Release executed by_____________________________________ (print name of student.) in favor of

the Atlantic Cape Community College and all of the employees, agents, servants and representatives thereof.

I will be participating in the upcoming trip to: (please print all information)


Date(s) of Travel

I have examined the itinerary for this trip, and I am fully familiar with the various modes of travel and accommodation schedule. In recognition and appreciation of the normal risks and dangers various modes of transportation necessary to participate in this trip, I do hereby agree to assume all such risks surrounding my participation in the trip, and the travel and accommodations related thereto.

I further do, for myself, my heirs, and personal representatives, agree to defend, hold harmless, indemnify and release and forever discharge Atlantic Cape any and all of its officers, agents, servants and employees from and against any and all damage or inconvenience to personal property and/or my person which may result from participation in this trip and related events.

I further understand that if a private vehicle is utilized to any College sponsored event, the automobile insurance is primary, and the College Student Accident insurance is not applicable.

I hereby certify that I have read this document, and I fully understand its terms and provisions. Any questions

that I have about the event described herein, and the contents of this document have been fully explained to my satisfaction.

In witness whereof, I have caused this release to be executed this _____ day of ______________ (month) _________ (year).

Student Signature

Advisor Signature

Date Submitted____________________________________________________________________

White- Business Services Yellow-Student Activities Pink-Security Gold-Student

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