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Hold Harmless Form

Use for on or off-campus activities. This data sheet to be filled out by organizer(s) of the activity. Please fill in any applicable blanks.

Ashtabula    
East Liverpool    
Geauga    
Kent    
Salem    
Stark    
Trumbull    
Tuscarawas    
Twinsburg Center    
  mm/dd/yy
(Field trip, site visitation, etc.)

(Privately owned, university, military, public)

(Specify faulty, graduate, student)

Name and address of outside organization(s) involved with this activity (Gov't agency, private company, individual)

Risks specific to this activity

Other than transportation, list any special accommodation(s) related to this activity (motel, restaurant, etc.)

Yes    
No    
Are there any students involved who are not age 18 or older?
Yes    
No    
Is the activity a requirement for the course?
Yes    
No    
Is the course a requirement for a degree program?
Yes    
No    
Is the activity listed as a course requirement in the catalog?