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New Jersey Liability Release Form 1

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This liability release form is provided by Richard Stockton College of New Jersey to release its future liability in case any injury or accident occurs to the participant in the Stockton Service-Learning Program.

New Jersey Liability Release Form 1
New Jersey Liability Release Form 1
Release of Liability
I, (print name), have voluntarily agreed to participate in the Stockton
Service-Learning Program, scheduled to begin on or around . This program involves personal
transportation from the school to the community-based site. I have attended a service-learning orientation and I believe
that I am physically, medically, and mentally capable of participating in such activity. If there are any medical or other
concerns that might limit my participation in such an event, I have advised appropriate personnel of such concerns. I am
agreeing of my own free will to participate in this activity and to the use of any equipment associated with this activity. I
agree that should any equipment or facilities at the community organization be damaged arising out of my participation
that I am financially responsible.
I have personally and willingly assumed responsibility of all known and unforeseen risks that may occur arising
out of my participation in this program. On behalf of myself, and any of my heirs, assigns, or successors, I hereby agree
to release and hold harmless Richard Stockton College of New Jersey and its officers, agents, servants, Board of Trustees,
and employees against any damage, claim, demand, liability, judgment, loss, expense, or costs arising from participation
in this activity, whether due to intentional acts or omissions or negligence of Richard Stockton College or any of its
employees, servants, or agents or those of third parties or organizations. I acknowledge and agree on behalf of myself, my
heirs, assigns, or successors, that I am releasing Richard Stockton College of New Jersey from any liabilities in law or
equity, however the liability may arise, for any injuries, damages, losses, or expenses to myself or my personal property. I
agree and consent that any disputes arising out of participation in this activity and any and all claims that I may bring
against the State of New Jersey and the Richard Stockton College of New Jersey and their employees as a result of this
activity shall be subject to the provisions of the laws of the State of New Jersey, particularly the New Jersey Tort Claims
Act (N.J.S.A. 59:1-1 et seq, New Jersey Contractual Liability Act, N.J.S.A. 59:13-1 et seq) and no other action for
monetary damages or other legal or equitable relief shall be brought in any other jurisdiction other than the courts of the
State of New Jersey.
I certify that I have read this release; I am at least 18 years of age or, if under 18, I have cosigned this form with a
legal parent or guardian; and that by my signature below, I bind myself, my heirs, assigns, administrators, and executors
to this agreement. I also realize that the community agency with which I will complete my service-learning hours intends
to take all necessary precautions against injuries and accidents; nevertheless, I agree that the staff, agents, and officers of
this agency are free from any responsibility for accidents or mishaps. I am aware that this activity carries with it certain
risks, included but not limited to driving to and from the activity. I agree to release and hold harmless the staff, agents,
and officers of the agency from or for any claim(s), liability, or damages that may be incurred against them or that may be
incurred as a result of an accident during volunteer placements. This release from liability includes theft, destruction of
property, or any other action(s) that may damage or destroy my personal property.
I submit that I am covered by emergency health insurance, either through Stockton College or privately. I transfer
and assign to any hospital or clinic in which I am confined or treated, should an accident occur, all hospitalization and
insurance proceeds that may be needed. I further agree and promise to pay any amount not covered by insurance.
PRINTED NAME SIGNATURE DATE
Course Acronym & Number: Instructor:
Participant Mailing Address:
Phone: Email:
Emergency Contact Info:
Name Phone
New Jersey Liability Release Form 1