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?



 

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