ASSUMPTION OF THE RISK FORM Name(Required) First Last Club/Class(Required) Start Date:(Required) MM slash DD slash YYYY End Date:(Required) MM slash DD slash YYYY (very specifically list here the potential risks involved that the student is assuming. If needed, attach a separate sheet of paper)(Required) I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to personal injury and loss of personal property (very specifically list here the potential risks involved that the student is assuming. If needed, attach a separate sheet of paper)I understand that in the event of accident or injury, personal judgment may be required by Mountain Empire Community College regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that Mountain Empire Community College may not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition. I further agree to abide by any and all specific requests by Mountain Empire Community College for my safety or the safety of others, as well as any and all of Mountain Empire Community College’s rules and policies applicable to all activities related to this program. I understand that the College reserves the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others. In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of my property which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury, damage to or loss of my property is directly due to the negligence of Mountain Empire Community College. I understand that this Assumption of Risk form will remain in effect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with the Dean of Student Services, at which time my visits to or participation in the program will cease.In case an emergency situation arises, please contact(Required) First Last Emergency Contact Phone No.(Required)I represent that I am 18 years of age or older and legally capable of entering into this agreement.I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal risks and conditions of my own free will. 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