ࡱ> KML` bjbj  m *  8& J4lNNNNN3333333$5h83 3 NN4d RNR 8N33m0 0 " Y3NB (9$y2:}3L40J428|8tY38 Y3$33@dJ4 $    MENDOCINO-LAKE COMMUNITY COLLEGE DISTRICT FIELD TRIP/EXCURSION NOTICE AND MEDICAL AUTHORIZATION--ADULT Field Trip/Excursion: Departure Date & Time: Return Date & Time: I understand that pursuant to the California Code of Regulations, Subchapter 5, Section 55450, by participating in the field trip(s)/excursion(s), I am deemed by law to have waived any claims against Mendocino-Lake Community College District for injury, accident, illness or death occurring during or by reason of the field trip/excursion. I understand and acknowledge that participation in this activity is completely voluntary and, as such, is not required by the district. I have no known medical condition(s), which may pose a risk to the health and safety of others or me by participating in the activity(ies). I agree to advise the district in writing of any medical, physical or health condition, which may be affected or in any way jeopardized by participating in a specific field trip/excursion. In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for my safety and welfare. It is understood that the resulting expenses will be the responsibility of the participant. Medical Insurance Carrier Policy No. Address In the event of accident or illness please notify: Name Address Phone I understand and acknowledge that unless specifically advised otherwise, the college is not providing the transportation and it is my responsibility to arrange for my transportation to and from the activity. If the college is providing transportation but I do not use the transportation, I am responsible to make my own arrangements and the college assumes no responsibility or liability of any kind. If the college is not providing transportation I further understand: The driver of the vehicle in which I am riding, either as driver or passenger, is not driving on behalf of or as an agent of the college, and the college has not verified the driving record of the driver, the liability insurance of the vehicle, or the condition of the vehicle; The college is in no way responsible, nor does the college assume liability, for any injury or loss which may result from my transportation; Although the college may assist in coordinating the transportation and/or recommend travel times, routes, car pooling, or caravanning, recommendation(s) or travel assistance provided is not mandatory.  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