Community Service : Western Day of Service

Statement of Due Warning, Assumption of Risk & Responsibility Form

The following must be read and completed by each person participating in Western Day of Service.

I                                                                                                voluntarily agree to participate in the Western Day of Service. I am aware that this is a Western Connecticut State University sponsored program and that the university’s Code of Conduct is in force.  I am held to the same standards of conduct as if I was on campus.  If I am found violating the Code of Conduct while volunteering, I understand I will be subject to the university’s judicial process.

I am aware of the inherent and/or latent danger (including but not limited to: risk of serious injury, the hazards of participating in this kind of program, accident or illness, or acts of God) of participating in such activity. I am further aware and have been advised that the University and/or its personnel will provide minimal supervision during this activity.  The following regulations will apply:

  1. No minors, without parental or guardian permission.
  2. No alcohol permitted on bus or mode of transportation or at any time during the program.
  3. It is the participants’ sole responsibility to strictly adhere to the departure schedule stated prior to trip commencement. Western Connecticut State University will not be responsible for those participants who fail to comply with this regulation.
  4. Western Connecticut State University assumes no responsibility for participants’ personal property and reserves the right to inspect any/all packages brought on board the vehicle of transportation.

Failure to comply with any/all of the regulations stated above will result in the termination of the participant’s involvement with Western Day of Service.

Knowing all this, I assume all risks that may arise from or in connection with this activity.  In addition, I do hereby agree and warrant to release and hold harmless the state of Connecticut, the Board of Regents of the Connecticut State Colleges and Universities and/or Western Connecticut State University, its agents and employees, from any and all liability, claims, demands, actions and causes of action whatsoever, arising out of or related to any loss, damage or injury resulting from my participation in this activity.

Being eighteen (18) years of age or older, I voluntarily agree to participate in this activity.

Student’s Signature:                                                                                         Date: __________

Student’s Printed Name:                                                                                

Signature of Parent or Guardian if student is under 18 years of age:

Parent/Guardian’s Signature: ________________________________ Date: __________

Parent/Guardian’s Printed Name: _____________________________