Dublin City School District
Program
2340C F5
Page 1 of 2
Revised 11/9/15
Parent/Guardian Disclaimer and
Acknowledgement Form with Assumption of the Risk and
Indemnification for District-Sponsored Global Trips
The parent/guardian or the student (or the student if the student is 18 years of age or older) is to read and complete
this form, have it notarized, and return it to the staff member in charge of the Global Trip.
• The staff member in charge of the Global Trip will submit the white copy to the school office along with a roster
of those students participating.
• No student may participate in the district-sponsored Global Trip without this completed form and a completed
form 2340C F1 (Medical Permission Form) on file in the school office.
______________________________________________________________________________________________
This disclaimer and acknowledgement, with assumption of the risk and indemnification, was executed on
•
_____________________________ by _______________________________________________, whose child/ward
(Date)
(Name of parent/guardian or the student, if 18 or older)
(or the student, if the student is 18 years of age or older) ____________________________________ (“the Student”)
(Name of student)
will be participating in a district-sponsored Global Trip to:
____________________________________________________________________________ (the “Global Trip”) on
______________________________.
(dates of Global Trip)
The undersigned acknowledges as follows:
A.
that the Global Trip is sponsored by or is affiliated with the Dublin City School District (“the District”)
and/or other school districts (the “Cooperating Districts”) in conjunction with the District; and
B.
that any and all teachers who travel with the students on the Global Trip are doing so as employees of the
District and/or the Cooperating Districts; and
C.
that students from Cooperating Districts may be participating in the Global Trip; and
D.
that the District and/or the Cooperating Districts has/have participated in planning or scheduling Global Trip
activities; and
E.
that the Student will abide by all relevant District policies and administrative guidelines, including but not
limited to the Student Code of Conduct; and
F.
that it is the sole responsibility of the undersigned to evaluate carefully the risks inherent in the Global Trip;
and
G.
that the undersigned has fully considered and is fully aware of the risks inherent in the Global Trip,
including, without limitation, dangers posed by willful or negligent conduct by the Student and/or by others,
and that, by participating in the Global Trip, there is a voluntary assumption of such risks on behalf of the
Student and by the undersigned; and
Program
2340C F5
Page 2 of 2
Revised 11/9/15
H.
that in exchange for the District's agreement to permit the Student to participate in the Global Trip, I, for
myself, the Student, my heirs, executors and assigns, release, covenant not to sue and agree to hold harmless
and indemnify the Dublin City School District, its Board of Education, and its individual board members,
employees and agents, including but not limited to the chaperones for the Global Trip, and any Cooperating
Districts, their Boards of Education, and their individual board members, employees and agents, including
but not limited to the chaperones for the Global Trip, for any act or omission and from any and all liability of
any kind, arising from negligence or otherwise, and from all damages which might result from the Student’s
participation in the Global Trip, including, but not limited to, property damage, bodily, personal or emotional
injury, including death; and
I.
that the District is not liable for any direct or related costs associated with this Global Trip; and
J.
That this disclaimer and acknowledgement, with assumption of the risk and indemnification, and all matters
or issues collateral thereto and/or arising from or related to the Global Trip shall be determined under,
governed by and construed in accordance with the internal laws (and not the law of conflicts) of the State of
Ohio; and
K.
that this disclaimer and acknowledgement, with assumption of the risk and indemnification, and all matters
or issues collateral thereto and/or arising from or related to the Global Trip are subject to the exclusive
jurisdiction of the state and federal courts in Franklin County, Ohio with respect to any suit, action or
proceedings relating to this Agreement and/or arising from or related to the Global Trip, and each party
waives any objection which it may have at any time to the laying of venue of any such proceedings brought
in such courts, waives any claim that such proceedings have been brought in an inconvenient forum and
further waives the right to assert, with respect to such proceedings, that such courts do not have jurisdiction
over such party.
I, the undersigned, have read the above carefully and understand and agree to all of its terms. I execute this
voluntarily and with full knowledge of its significance.
Name of Student (please print): ____________________________________________________________________
Student’s signature (if 18 years of age or older): ____________________________________________________
Parent/Guardian Signature: _______________________________________
Date: ____________________
The State of Ohio, County of _________________________________.
The foregoing instrument was acknowledged before me this __________ day of __________________________
by ______________________________________________________.
_______________________________________
Notary Public
My commission expires: __________________
Original: school
Copies: Teacher and Parent/Guardian