University of Vermont Department of Risk Management

Acknowledgment of Risk and Consent for Treatment during Field Laboratories & Field Trips

Section 1                             (To be completed by field lab LEADER)

Class:   ______________________________________________________________________________

Field lab leader: __________________________________Contact: _______________________________

Address: _____________________________________________________________________________

Field lab date(s): _______________________________________________________________________

Equipment/supplies to be provided:

                - by participant: _________________________________________________________________

                - by field trip leader: _____________________________________________________________

Immunizations required (check with Center for Health & Wellbeing): ________________________________

_______________________________________________________________________________________

Physical activities to be undertaken include: __________________________________________________

_______________________________________________________________________________________

Risks inherent in this field trip include bodily injury due to: ______________________________________

______________________________________________________________________________________

(Form continued on next page.)

Section 2               (To be completed by field lab PARTICIPANT)

 I acknowledge that there are certain risks inherent in field laboratories, including but not limited to those indicated in Section 1.  I acknowledge that all risks cannot be prevented.   I represent that I am physically able, with or without accommodation, to participate in this field laboratories for this course, am able to use the equipment and/or supplies described above, and have obtained the required immunizations, if any.

 Should I require emergency medical treatment as a result of accident or illness arising during the field lab, I consent to such treatment. I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment.  I will notify the trip leader in writing if I have medical conditions about which emergency medical personnel should be informed.

  I will follow the student code of conduct as described in the UVM Code of Student Rights & Responsibilities.
I will not possess or use alcohol or unlawful substances while participating in course work. I will wear a seatbelt at all times during transportation to and from the field site.

_____________________________________________________

Name (please print)

__________________________________________                 ________________________________

Signature                                                                                                                             Date

_____________________________________                _____________________________

Signature of parent/guardian (if participant is a minor)                                                              Date

Section 3             General Information

 To request disability accommodations for this field trip, please notify your trip leader or contact the ACCESS Office at least 10 days in advance of the trip by calling (802) 656-7753 (voice); (802) 656-3865 (TTY); or (802) 656-0739 (FAX).

 Immunizations may be obtained through the Center for Health & Wellbeing  (802) 656-0847 or your primary care physician.                                                                                                                                 

Section 4                 Health Insurance Information

Participant's Health Insurance Company:                   _______________                          Policy #    _