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Insurance & Risk Management
ENVIRONMENTAL HEALTH & SAFETY
TEL NO: (818) 677-2079
FAX NO: (818) 677-5853
MAIL DROP: 8284
Academic Field Trip
Informed Consent Form
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I. THE UNDERSIGNED HEREBY REQUESTS ACCEPTANCE TO PARTICIPATE IN THE CSU, NORTHRIDGE:
(Name of department and college)
II. DESCRIBE THE ACTIVITY:

HEREIN AFTER REFERRED TO AS "ACTIVITY" THAT BEGINS ON AND ENDS ON .
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In consideration of my voluntary participation in the above captioned activity, I hereby waive all claims of action against the State of California; the Trustees of the California State University; California State University, Northridge; its auxiliary organizations; and the officers, directors, employees, and agents, all of which are collectively hereinafter referred to as the "State", arising out of my voluntary participation in the activity and hereby release, hold harmless, and discharge the State from all liability in connection therewith.

Knowing, understanding, and fully appreciating all possible risk, I hereby expressly, voluntarily, and willingly assume all risk and dangers associated with my participation in this activity. These risks could result in damage to property, personal and/or bodily injury or death.

In addition, I have been advised to obtain personal medical coverage either through the University Health Center or a medical insurance carrier of my choosing. Furthermore, I agree to use my personal medical insurance as the primary medical coverage payment if accident of injury occurs.

I have read this waiver and release and understand the terms used in it and their legal significance. This waiver and release is freely and voluntarily given with the understanding that right to legal recourse against the State is knowingly given up in return for allowing my participation in the activity.

My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

Participant Signature:_______________________________ Date: ______________
Print Name: Phone:

Parent's or Guardian's Signature:______________________ Date: ______________
(IF PARTICIPANT IS A MINOR)  
Print Name: Phone:

Instructor's Signature:_______________________________ Date: ______________
Print Name: Phone: