Kinesiology Release Form

As per College policy or as follows in the absence of such policy language:

I, ______________________________________________, wish to participate in the following College of Micronesia-FSM course or program, PE 101j Joggling, as a student. I understand that this class is a voluntary program and is not required for my graduation. I agree to abide by all safety rules and regulations in effect during this course or program.

Please check one of the following:

___ At the current time I am in good health, I am not aware of any diseases, illnesses, or physical conditions, and have not been advised by a doctor or other medical practitioner that I have any diseases, illnesses or physical conditions, that may affect my participation in or completion of the above-described program.

____ I have the following medical conditions that may affect my ability to participate in or complete the above-described program.



I wish to participate in the above-described course or program at the College of Micronesia -FSM, and agree that the College of Micronesia-FSM, and their employees are not responsible for my participation in this program, or for any injuries that may occur during my participation in this program, or by the utilization of their equipment.

Further, the instructor of this course or program in the event that he or she believes, with or without medical evidence, that I may not participate in this course or program, or that I have physical limitations that may prevent me from participating in this course or program, has absolute discretion, and may terminate my continued participation in the course or program, at any time, with or without a valid reason. However, this discretion is not an obligation of the College of Micronesia-FSM, or its employees, nor a duty, and any failure to prevent participation on my behalf, or to limit the amount of activities involved in the course or program on my behalf, does not give rise to a renunciation of or exception to this knowing and voluntary waiver.

As I result, I agree, and voluntarily assume all responsibility for my own safety and well-being, while participating in the course or program, and agree to waive any claims for liability, injury, or other damages as a result of injury or death, against the College of Micronesia-FSM or their employees. I enter into this waiver knowingly and in advance of my participation in the course or program. By signing this waiver I will forever release any future claims against the College of Micronesia-FSM and their employees, arising out of any accident, injuries, death or other damages, on behalf of myself or my heirs or dependents, due to any accident, or other mishap, including acts of god, that may arise upon my participation in the course or program.

Dated: ____________     _________________________
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