LIABILITY WAIVER AND INSURANCE STATEMENT

I acknowledge that my participation in the __________________________________

(course or activity) field trip to _____________________________________(destination) on

______________________, 200__, with__________________________________ (name of

faculty or staff sponsor) may involve risks including but not limited to motor vehicle accidents and other potential personal injuries and property damage. I assume responsibility

for all risks. I indemnify and hold harmless N. C. State University, its trustees, officers,

employees, and agents from any liability arising from or proximately caused by my

participation in this field trip.

I further acknowledge that I have comprehensive health insurance coverage that will be

in effect on the date(s) of this field trip. The insurance company is

__________________________________________________________________________,

and my policy number is________________________________________.

SIGNATURE_________________________________________ DATE_______________

If participant is less than 18 years of age:

I am fully aware of the risks that may be involved, and I consent to have my child

participate in the aforementioned field trip. Insurance coverage is indicated above.

___________________________________________________ _____________________

PARENT/GUARDIAN SIGNATURE DATE

FORM IRM-04 (REV. 12/02)