Caution: This is a release of legal rights. Read and understand it before signing.

Phoenix College is a non-profit educational institution. References to Phoenix College ("College") include the Maricopa County Community College District ("MCCCD"), its officers, officials, employees, volunteers, students, agents, and assigns.

I (print your name) ______________________________________, freely choose to participate in the Chemistry Laboratory Course CHM 130LL (henceforth referred to as the Program).

In consideration of my voluntary participation in this Program, I agree as follows:

SPECIFIC HAZARDS OF PROGRAM:
» Exposure to possible chemical irritation
» Inhalation of chemicals
» Exposure to flammable materials
» Possibility of burns
» Exposure to possible broken glass
» Exposure to toxic organic, inorganic, and other hazardous substances

HEALTH AND SAFETY: I have been advised to consult with a medical doctor with regard to my personal medical needs (to include pregnancy especially in the first trimester). I state that there are no health-related reasons or problems that preclude or restrict my participation in this Program. I have obtained the required immunizations, if any.

I recognize that College is not obligated to attend to any of my medical or medication needs, and I assume all risk and responsibility therefore. In case of a medical emergency occurring during participation in this Program, I authorize in advance the representative of the College to secure whatever treatment is necessary, including the administration of an anesthetic and surgery. College may (but is not obligated to) take any actions it considers to be warranted under the circumstances regarding my health and safety. I agree to pay all expenses relating thereto and release College from any liability for any actions.

ASSUMPTION OF RISK AND RELEASE OF LIABILITY: Knowing the risks described above, and in consideration of being permitted to participate in the Program, I agree to release, indemnify, and defend College and their officials, officers, employees, agents, volunteers, sponsors, and students from and against any claim which I, the participant, my parents or legal guardian or any other person may have for any losses, damages or injuries arising out of or in connection with my participation in this Program.

SIGNATURE: I indicate that by my signature below that I have read the terms and conditions of participation and agree to abide by them. I also agree to abide by the safety rules and advisories outlined in each online laboratory assignment and the safety sheets that accompany the Chemistry Kit. I have carefully read this Release Form and acknowledge that I understand it. No representation, statements or inducements, oral or written, apart from the foregoing written statement have been made. This Release Form shall be governed by the laws of the State of Arizona which shall be forum for any lawsuits filed under or incident to this Release Form or to the Program. If any portion of this Release Form is held invalid, the rest of the document shall continue in full force and effect.

_______________________________________     __________________________________________
Signature of Program Participant                                   Signature of Parent or Legal Guardian
                                                                                            (if student is a minor)

___________________________________             ______________________________________
    Date                                                                             Date