Agreement Form - Miracosta College printable pdf download

AGREEMENT FORM

Bring this form and your course syllabus with you the first time you visit your community organization.

RETURN COMPLETED FORM TO THE SERVICE LEARNING CENTER PRIOR TO BEGINNING SERVICE

MiraCosta College Service Learning Office, Oceanside Campus - Room 3306, (760) 795-6616

Please read the following statement carefully. By signing this agreement form, you are agreeing to participate in

a service activity and waive district liability as set forth in this declaration for said participation.

All persons traveling to and from the volunteer site shall be deemed to have waived all claims against the District or the

State of California for injury, accident, illness or death occurring during the trip. I agree that any accidents or infractions

(moving violations) incurred while driving my own vehicle are the sole responsibility of myself. I will not hold MiraCosta

College District, its employees and agents responsible for any such damage, injury or liabilities. Further, injuries and or

illnesses occurring during or as the result of my participation in the service learning class should be covered in

accordance with the premiums of the student insurance program as the secondary health insurance carrier.

Student’s Name: ________________________________________Student ID #:_______________________

Your address will be pulled from SURF. If you have recently moved and have not updated your records, please submit a Change of

Information Form to the Admissions and Records Office.

Phone: _______________________________________ Semester: _________________________________

Course: __________________________________________Instructor:_______________________________

Circle the number that most accurately indicates your opinion

Strongly

regarding the statements below

Agree

Disagree

I am concerned about community issues.

I am responsible for doing something to improve my community.

Contributing my time and skills will make the community a better place.

♦ Please initial for essay and/or photo release:

I hereby give permission to the SLVC to publish photographs of me involved in service activities.

_______________

I hereby give my permission to print my service learning essay in the annual edition of Reflections.

_______________

Service Learning Site:

(Organization MUST be an APPROVED MiraCosta Service Learning Site)

Name of Organization:

____________________________________________________________________________________

Supervisor: ___________________________________________ Phone: ___________________________

E-mail:__________________________________

Approx. # of service hours to be completed: __________

Duties to be performed: ____________________________________________________________________

_____________________________

_________

_________________________________

_________

Site Supervisor’s Signature

Date

Student’s Signature

Date

I agree to accept the above-named student

I agree to the terms set forth above and to

and provide adequate training and supervision

perform my duties to the best of my abilities.

at this service learning site.

I have read the liability waiver and agree to its terms.

Revised: 8/15

Agreement Form - Miracosta College

Related Articles

Related forms

Related Categories