Dr. Terry R. Bacon Leadership Center

Emergency Contact/Liability Waiver

**The form below must be submitted before you are approved to participate in FLC-related/sponsored travel**

I am aware that participation in the activity I list below can be dangerous and may involve RISK OF INJURY or DEATH. I understand that by participating in the activity identified below, I may be exposed to risks and dangers, such as Acts of God, inclement weather, environmental conditions, equipment malfunction, acts of a third party, etc.. I further understand that my participation in this activity, as well as travel to and from related events, may result in serious injury and may impair my future abilities to earn a living or to engage in other business, social and recreational activities.  Given all of these risks, however, I still intend to participate in this activity.

By my electronic signature below, I hereby release and hold harmless the State of Colorado, the Board of Trustees for Fort Lewis College, and Fort Lewis College, its officers, faculty, employees and agents (collectively Fort Lewis College), from any and all liability that may arise from my participation in the below-referenced activity. I further agree not to sue, or otherwise assert claims, against Fort Lewis College arising from my participation in the below-referenced activity. I further understand and represent that:

1. This document has specific legal implications and I have had the opportunity to have counsel review this document before I have signed;

2. I am eighteen years of age or older, and of sound mind; or, if under eighteen years of age, my parent/guardian has given consent for my participation in this activity.

3. While participating in this activity, I am subject to all Fort Lewis College policies and procedures, including the Student Conduct Code; I will follow directions and guidelines from Fort Lewis College staff.

4. My emergency contact information will be provided below.










RadDatePicker
Open the calendar popup.

RadDatePicker
Open the calendar popup.








Submit