STATEMENT OF RESPONSIBILITY, RELEASE OF LIABILITY, WAIVER,

DISCHARGE, AND COVENANT NOT TO SUE

Release executed by________________________________________, whose home address
[Name of Participant]
is ___________________________________________________, to Nevada State College.
[Address of Participant]
Student ID #
Course #
Semester & Year

___________
___________
___________

As part of the Internship for Credit, Independent Study, or Field Experience for Credit course
listed above (hereafter called the Course), I am participating in work at one or more off-site
locations for the duration of the semester.
Transportation:
Students will travel to and from their work sites by public transportation or in their own private
vehicles over the course of the semester. Some worksites may be remote without available
medical facilities or cell phone reception. In case of an emergency, call 911 from a landline
telephone or contact a park ranger or other local authority if cell phone coverage is not
available.
Possible Risks:
The risks that may be inherent in this work include: vehicular accidents while traveling in
private vehicles to or from the work locations, moderate physical exertion, and all types
of risks associated with office, wilderness exploration, or basic laboratory work.
Risks for field courses may include crossing a two-lane highway by foot to reach a field
site, walking on uneven and rocky terrain, cliffs, thorny plants, cacti and the like,
encountering animals such as snakes and scorpions, and adverse weather conditions of
all types such as rain, lightening, snow, and cold or hot weather.
Risks for laboratory-based internships may include exposure and handling of chemicals,
glassware, needles, and/or organic specimens under supervision.
Acknowledgment of Risks:
I fully understand and appreciate the dangers, hazards, and risks inherent in this Course which
could include serious bodily or even fatal injuries, and property damage or theft. Knowing the
dangers, hazards, and risks of this experience, and in consideration of being permitted to
participate, on behalf of myself, my family, heirs, personal representative(s), and insurers, I
hereby agree to assume all the risks and responsibility surrounding my participation in this
Course, and the private transportation to and from the site(s).
_______
[Initial here
Release of Legal Rights:
I agree to release, waive, forever discharge, and covenant not to sue Nevada State College, its
governing board, the State of Nevada, and their respective officers, agents, and employees
(hereafter called the Releasees), from and against any and all liability for any harm, injury,
including death, damage, claims, demands, actions, causes of action, costs, and expenses of
any nature that I may have, or that may hereafter accrue to me, arising out of or related to any
loss, damage, or injury, including death, that may be sustained by me or by any property
belonging to me, whether caused by the negligence or carelessness of Releasees, or by the
actions of any third party, while in, on, upon, or in transit to or from the premises where the
activity associated with the Course is being conducted. I further agree to hold harmless,

indemnify, and defend Releasees from any claim by me or my heirs, or anyone else acting or
purporting to act on my behalf or on behalf of my heirs arising out of my participation in the
course.
_______
Initial here
I agree to come fully prepared to minimize risks associated with this Course as suggested by
my Course instructor. I further avow that I am in sufficient physical condition to safely participate
in this Course. I also represent that I am responsible for any medical costs that may be incurred
as a result of sickness or injury to me through participation in this Course, and that Releasees
shall have no responsibility for the payment of same. I understand that the College is not
maintaining any health or accident insurance on my behalf.
_______
Initial here
I understand and agree that Releasees will not have medical personnel available at some
locations of the Course. I give permission to NSC to authorize emergency medical treatment for
me, as may be deemed necessary, if I am unable to authorize such treatment.
_______
Initial here
I further agree that this Release shall be construed and enforced in accordance with the laws of
the State of Nevada, regardless of where any injury or damage occurs, and that the venue for
any dispute, claim or action arising out of or related to this Course shall be the Eighth Judicial
District Court in and for the County of Clark, Nevada. If any term or provision of this Release
shall be held illegal, unenforceable, or in conflict with any law, the validity of the remaining
portions shall not be affected thereby.
I am at least eighteen (18) years of age and fully competent to sign this Release, and that I
execute this Release for full, adequate, and complete consideration fully intending to be bound
by the same. I understand that I sign this document as my own free act and deed; and that no
oral representations, statements, or inducements, apart from this agreement itself, have been
made. I agree that my signature denotes my affirmation that I will abide by all state, local and
federal laws as well as the Nevada State College Student Code of Conduct, while participating
in this Course. Violation of these rules may result in the immediate termination of my
participation in the Course.
THIS IS A RELEASE OF LEGAL RIGHTS. READ AND BE CERTAIN YOU UNDERSTAND IT
BEFORE SIGNING.
STUDENT/PARTICIPANT:

PARENT/GUARDIAN (If participant is

under 18):

________________________
(Signature)

___________________________
(Signature)

_______________________
(Printed Name)

____________________________
(Printed Name)

_______________________
(Date)

___________________________
(Date)

Please return this signed form to Dr. Richard Yao, Director of Student Development,
Nevada State College Liberal Arts and Sciences Building, Rm 253