Print this form then complete it in ink.
I hereby request that I be permitted to attempt to complete a BASIC MOTOR SKILLS TEST, AGILITY PRACTICE, and /or SWIM TEST, which are administered by the Institute of Public Safety Criminal Justice Testing Center, a division of Broward Community College. I hereby release Broward Community College, its employees and its agents from all liability arising from their developing and/or conducting such test(s). Further, I voluntarily release, waive and discharge Broward Community College, its employees and its agents for any and all claims, demands, damages, and causes of action of any nature whatsoever which I, my heirs, my assigns or my successors may have against Broward Community College, its employees, or its agents on account of, or by reason of my engaging in the BASIC MOTOR SKILLS TEST, AGILITY PRACTICE, and/or SWIM TEST.
| _____________________________________________ Signature |
______________________________ Date |
| _____________________________________________ Name (printed) |
______________________________ SOCIAL SECURITY NUMBER |
| _________________________________________ C.J.T.C. ID# |
|
| ____________________________________________ WITNESS |