Student Agreement & Medical Release Form

*Student I.D. Number

*First Name

*Last Name

*Address (Street Number)

*City

*Zip Code

Phone Number

Cell Phone Number

*Email Address

*Class Name

*Class Reference Number

*Faculty/Staff/Advisor Name

Faculty/Staff/Advisor Phone Number

*Faculty/Staff/Advisor Department

Semester/Session

Fall

Winter

Spring

Summer

Semester/Session Year

Travel Destination 1

Travel Destination 1 Date

Travel Destination 2

Travel Destination 2 Date

Travel Destination 3

Travel Destination 3 Date

*General Description of Activities

Waiver: All persons making the field trip or excursion shall be deemed to have waived all claims against the District or the State of California for injury, accident, illness, or death occurring during, or by reason of, the field trip or excursion. (Reference: Title 5 section 55220)
Medical Authorization: In the event of illness or injury while participation in the above referenced activity, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical, dental diagnosis or treatment, hospital care and emergency transportation from a licensed physician, surgeon, and/or dentist as deemed necessary for my safety and welfare.

Participant's Private Medical Insurance Carrier

Policy Number

Insurance Carrier Phone

Medical Condition

Check here if you have a special need or medical condition(s)

Medical Condition Description (If you stated a medical condition above)

*Emergency Contact Name

Emergency Contact Relationship

*Emergency Contact Phone Number

Emergency Contact Cell Number

Transportation
- Field Trips: I will use transportation provided by Mt. San Antonio College for field trips
- Off-Campus Meetings: If an off-campus meeting requires me to use personal transportation, I understand that Mt. San Antonio College (its Board of Trustees, officers, employees, agents, representatives or volunteers) is in no way responsible , nor assumes liability, forany injuries, losses, cloaims or actions resulting from, arising out of or incident to, the non-District transportation. I understand that although the District may recommend travel time and/or routes to and/or from this event such recommendations are not mandatory and do not in any way constitute District sponsorship of, or responsibility for, my transportation. I further acknowledge that the District does not provide any type of insurance, including liability, collision, or comprehensive, for students who provide their own transportation or provide transportation for other individuals in connection with an excursion/ Field trip activity.

Agreement to Terms (Student and/or legal guardian)

My checkmark below acknowledges that I have carefully read these provisions and I fully understand and willingly agree to abide by these terms.

*Date of Signature

Standards of Behavior for On-Campus and Off-Campus Activities

Mt. San Antonio College students are expected to conduct themselves in a respectable manner, as the actions of one individual can affect the reputation of the College. While participating in activities, students are serving as a representative of Mt. San Antonio College and must uphold the College Standards of Conduct.

Some violations may include:

Causing, attempting to cause, or threatening to cause physical injury to another person.
Possession, sale, or otherwise furnishing any firearm, knife, explosive or other dangerous object, including but not limited to, any facsimile firearm, knife, or explosive, unless, in the case of possession of any object of this type, the student has obtained written permission to possess the item from a College employee, which is concurred by the College President/CEO.
Unlawful possession, use, sale, offer to sell, or furnishing, or being under the influence of, any controlled substance listed in Chapter 2 (commencing with Section 11053) of Division 10 of the California Health and Safety Code, an alcoholic beverage, or an intoxicant of any kind; or unlawful possession of, or offering, arranging or negotiating the sale of any drug paraphernalia, as defined in California Health and Safety Code Section 11014.5.
Engaging in harassing or discriminatory behavior based on national origin, religion, age, sex (gender), race, color, medical condition, ancestry, sexual orientation, marital status, physical or mental disability, or because a person is perceived to have one or more of the foregoing characteristics.
Willful misconduct which results in injury or death to a student or to College personnel, or which results in cutting, defacing, or other injury to any real or personal property owned by the College or on campus.

Disruptive behavior, willful disobedience, habitual profanity or vulgarity, or the open and persistent defiance of the authority of, or persistent abuse of, College personnel.
Harassment of students and/or College employees that creates an intimidating, hostile, or offensive environment.
Lewd, indecent, or obscene conduct on College-owned or controlled property, or at College-sponsored or supervised functions.
The rules pertaining to the activity or event must be followed.

Acknoledgement of Standards of Conduct

I further understand that I must adhere to the complete Standards of Conduct Policy and, if violated, I am subject to appropriate disciplinary procedures which could lead to suspension and/or expulsion determined by the severity of the incident.