AMARILLO JUNIOR COLLEGE DISTRICT
Waiver of Liability for Student Travel
STATE OF TEXAS
COUNTY OF POTTER
Date(s) of Travel:
Program/Conference:
Club/Organization:
I, ___________________________________, AC ID #____________________, do represent to Amarillo Junior College
Name
District that I was born on ___________________________, that I have no physical infirmities nor defects except
MM/DD/YYYY
_______________________________________________________________________________________________________, and
I do release the College District from any and all claims for damages, including but not limited to hospital and medical expenses and
loss of income, growing out of injury or death arising from participation in the educational programs in which I am enrolled. I further
release the College District from any and all claims for damages growing out of injury or death arising from participation in a College-
sponsored program due to any personal defects or physical infirmities that I have listed above. This waiver will remain in effect
throughout the period in which I am enrolled as a student in any class or program sponsored by Amarillo College. I further certify that
I have read and understand the “Amarillo College Student Rights and Responsibilities” publication.
Also, I am aware of the policies concerning student travel, and I understand that I must furnish receipts for all travel-related
expenditures for with I expect reimbursement. I understand that no alcoholic beverages or illegal drugs will be bought, consumed or
allowed at any time during student travel, and that all expenditures must have prior approval of the student organization’s faculty
sponsor according to Student Services’ published guidelines for student travel.
Student’s Signature _____________________________________________________________ Date __________________________
*If the student executing the waiver has not reached his/her 18
th
birthday, the following consent must be executed by a parent
or the guardian of the minor:
I, __________________________, of ________________________________, consent to the foregoing waiver and release.
Parent/Guardian Student Name
Parent/Guardian Signature _______________________________________________________ Date __________________________
EMERGENCY CONTACT INFORMATION
Name: ____________________________________________ Name: ____________________________________________
Relation: __________________________________________ Relation: __________________________________________
Phone Number: _____________________________________ Phone Number: _____________________________________
