Fairleigh Dickinson University

Assumption of Risk and Release Form for Students

Name of Participating Student (Print): Dianne Rivera

Address: 281C Reichelt Rd New Milford, NJ Campus:  Florham  Metro

Cell #: 201-410-7486 Student I.D. 1990006 Major: Musical Theatre

Description of Field Trip: A day trip to Point Pleasant, a beach with a boardwalk.

Staff/Faculty Trip Leader: Jillian Keshecki

Destination(s): Point Pleasant, NJ

Date(s): 8/27/21

Transportation:
FDU Van – Round Trip (Public Safety Officer driver)

I am a student at Fairleigh Dickinson University (“FDU”) and have chosen voluntarily to participate in the trip described
above (the “Trip”), and know, understand and voluntarily assume all risks inherent in the scope of participating in any and
all of the activities offered during the Trip including but not limited to transportation, walking hazards and any touring
upon arrival at destination. (“Trip”) is understood to include all activities at destinations, and all student personal travel
arrangements to and from such destinations.

I FULLY AND COMPLETELY ACKNOWLEDGE THAT THE INHERENT RISKS NOTED ABOVE DO NOT
REFLECT ALL OF THE RISKS ASSOCIATED WITH THIS ACTIVITY, AND THAT THE RISKS REFERENCED
ABOVE IN NO WAY LIMITS THE EXTENT OR SCOPE OF THIS AGREEMENT.

I hereby acknowledge that I have voluntarily and freely elected to participate in this activity, and that I am not required to
do so.

I acknowledge I will be using the FDU transportation provided to the group.

I understand and agree that Fairleigh Dickinson University and/or its representatives assume no liability in the event of
accident or illness, nor for damage or injury to person or property of any nature whatsoever from the time I depart until
the time I return. I freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury,
death, property damage or loss resulting therefrom.

I acknowledge that it is my responsibility to take every precaution to safeguard my health and to protect my personal
belongings from damage or theft.

I understand that, although FDU has organized the Trip, it cannot eliminate all risks or guarantee my safety while I am on
the Trip With knowledge of this information, I have made the independent judgment to participate in the Trip.

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1. Health Insurance; Medical Care; Health and Safety Concerns: I carry valid and current medical insurance and have
a valid insurance identity card to bring. I have determined that this insurance is adequate to cover injuries or illnesses that
I may sustain while participating in the Trip. I will be solely responsible for payment in full of all costs of medical care I
may receive while on the trip.

I authorize FDU to obtain appropriate health care for me in the event that I need it but am unable to obtain it for myself. I
further agree to hold harmless and indemnify FDU for any and all actions taken by FDU to provide necessary emergency
medical care to me during the Trip. I also understand and agree that if I experience serious health problems, suffer an
injury, or am otherwise in a situation that raises significant health and safety concerns, then FDU may contact my parents
or any other person whose name I have provided as my “emergency contact.” I understand that FDU ordinarily will not
initiate such contact without first having a discussion with me. DR (initial)

2. Standards of Conduct: I recognize that it is an important personal obligation to, and I promise to, conduct myself in a
manner compatible with local laws and regulations; with FDU’s policies and standards for student conduct (including
without limitation those set forth in the Student Handbook and in any Trip-specific materials); with the policies of my host
institution (if any); and with any instructions given by the Trip leaders or the host institution. I promise to act responsibly
and will become informed of, and will abide by, all such laws, regulations, policies and standards I agree that FDU has the
right to enforce all standards of conduct described above.

My behavior is my responsibility and not that of the Trip Leader, chaperone and/or professor or the University. If my
behavior is such that it disrupts the goals of the trip, the designated University authority in charge will make arrangements
for my early departure. I will incur any additional cost as a result of such a matter. DR (initial)

3. Travel Arrangement: I understand that FDU does not represent or act as an agent for, and cannot control the acts or
omissions of any transportation carrier, lodging provider, tour organizer or other provider of food, goods or services
involved in the Trip. I understand that FDU is not responsible for matters that are beyond its control, and that it cannot
warrant the safety or convenience of the circumstances under which I will find myself during the Trip. DR (initial)

4. General Release: Knowing the risks described above, I agree, on behalf of my family, heirs and personal
representative(s), to assume all the risks and responsibilities surrounding my participation in the Trip. To the maximum
extent permitted by law, I release, hold harmless and agree to indemnify FDU, and its officers, directors, faculty, staff,
representatives, employees and agents, from and against any present or future claim, loss or liability for injury to person
or property which I may suffer, or for which I may be liable to any other person, related to my participation in the Trip
(including periods in transit to or from my destination), resulting from any cause, including but not limited to ordinary or
gross negligence.

I certify that I am 18 or older. I have carefully read and freely signed this Assumption of Risk and General Release
Form. I understand and agree that no oral or written representations can or will alter the contents of this document. I agree
that this agreement shall be governed by the laws of the State of New Jersey.

This is a Release of Legal Rights – Read and Understand Before Signing

Signed: Dianne Rivera Date: 8/27/21

Student Name (print): Dianne Rivera

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Emergency Contact Information:
In the event of an emergency, every effort will be made to contact the following individuals(s):
One contact MUST be provided.

Name: David Rivera Relationship: Father

Work: China Construction Cell: 551-580-6806

Name: Ivelisse Rivera Relationship: Mother

Work: Bank of America Cell: 201-575-2142

Name and phone number of primary care physician:

Dr. Basil Bruno, 201-291-2323

Insurance Coverage:
Fairleigh Dickinson University requires that all students have appropriate accident and medical insurance coverage. It is
your responsibility to provide for medical insurance and to pay any deductible expenses or any other medical expenses
that are not covered by the insurance.
Please initial here to indicate that you have read and fully understand this paragraph: DR(initial)

Insurance Company: Aetna Life Insurance Company Policy #: 823428396

Group #: 0326475-010-00155 Name of Insured: Dianne Rivera

Insurance Phone Number/Contact Name: 1-877-444-1012

Medical History:
The following information is confidential and will be used only for aiding University personnel and emergency personnel
in providing appropriate medical care in the event of an emergency.
Are you allergic to any medications or food? Yes If yes, what medication or food? Shellfish, grass, pollen
Are you currently taking any medication? No If yes, please list medications: ______________________________________
Please describe any condition for which you are currently being treated: _________________________________________________

The information I have provided about my medical history is accurate to the best of my knowledge.
Dianne Rivera ________________________________
Signature Date 8/27/21

Alcohol & Drug Policy:

Fairleigh Dickinson University and the Office of Student Life endorse an alcohol and drug free philosophy. This prohibits
alcohol consumption or the illegal or irresponsible use of drugs by anyone, regardless of age, participating in the Trip.
Violation of this policy will result in removal from participation in any and all of the activities associated with the Trip.
Furthermore, a violation may result in disciplinary proceedings under the guidelines of the Fairleigh Dickinson University
Student Code of Conduct.
Your signature indicates that you have read and agree to the terms set forth in the Alcohol & Drug Policy.

Dianne Rivera ________________________________

Signature Date 8/27/21

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