Laker Athletics Activity/Program Release and Waiver of Liability

Mid Michigan College Student Activity/Program/Sport Travel Release
Student Name*

First NameMiddle NameLast Name
Mid Michigan College Student ID Number*
You can find your Mid Michigan College Student ID Number on your Mid Michigan College Student ID Card or in myMid.
Phone Number*

Area CodePhone Number
Mid Mich Email*
example@midmich.edu
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you 18 years of age or older?*

YesNo
Travel Information
Is the travel connected to a Laker Athletics team?*

YesNo
For which team are you travelling?*

BaseballMen's BasketballWomen's BasketballBass Fishing (co-ed)Men's BowlingWomen's BowlingClay Target Shooting (co-ed)Men's Cross CountryWomen's Cross CountrySoftball
Trip Name*
Trip Destination*
Trip Start Date*

MonthDayYear
Trip End Date*

MonthDayYear
Name of Activity/Program Director*

First NameLast Name
Mid Mich Email of Activity/Program Director*
example@midmich.edu
As a student at Mid Michigan College (Mid), I, the undersigned, have requested permission not to travel with the activity/program/team as indicated during the upcoming trip. I understand this travel is considered an official college-sponsored activity, event, or business during which time I am under the supervision of Mid staff, and that when I travel separately and/or once I leave such supervision, I assume the risks associated with traveling to/from this activity separately, which risks include but are not limited to physical or psychological injury, pain, suffering, illness, disability (including paralysis), economic or emotional loss, and/or death. In consideration for being allowed to travel separately from this activity/program/sport, on behalf of myself and my next of kin, heirs, and representatives, I release from all liability and promise not to sue Mid, the Board of Trustees, and their employees, officers, directors, volunteers, and agents (collectively "Mid") from any and all claims, including claims of Mid’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my decision to travel separately. Furthermore, I agree to hold Mid harmless from any and all claims, including attorney's fees or damage to my personal property that may occur as a result of my separate travel from this Activity/Program/Sport. If Mid incurs any of these types of expenses, I agree to reimburse the College. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
Student Signature*

Clear
Date*

MonthDayYear
Student Signature*

Clear
Date*

MonthDayYear
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Mid Activity/Program/Sport Director Signature*

Clear
Date*

MonthDayYear
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Mid Michigan College Student Activity/Program/Sport Travel Release

Travel Information