BLINN HOME BRENHAM BRYAN SCHULENBURG SEALY
Service Learning

 


Service Learning
Student Agreement Form

* required field


Student Information    
 
Student First Name *   Student Last Name*
 
Student Address*   Student ID number*
 
City* State* ZIP*   Home phone* (If no home phone type "N/A")

 
Email address Alternate phone  
 
Emergency contact person Telephone  
 
Community Partner (Agency or organization) Telephone  
 
Community Partner Supervisor's name Telephone (if different)  
Academic period* Campus*  
     
Year Fall Spring Summer   Bryan Brenham Schulenburg Sealy    
   
Course* A seperate form is required for each Service Learning course   Faculty*  
  Student Agreement (Form will not be submitted unless terms and conditions are agreed to. )
 

As a student committed to a service-learning component in my education, I agree to complete the required time in fulfillment of the service-learning component during the current academic semester. Blinn College has my permission to use all or any part of my statement and/or my image (photograph) related to my experience in service learning activities in any advertisement (printed and/or electronic) and any publication promoting the college and/or its programs.

If you do not agree to the terms and conditions stated above, check here.

  Assumption of Risk Statement
(Only students over 18 may submit form online. For minors, please return printed form to your instructor with a legal guardian's signature.)
18 years of age or over
Under 18 years of age


I, the undersigned, being 18 years of age or older, or in the capacity of a parent or legal guardian for the student identified above, do hereby acknowledge that there may be risks of physical harm and injury inherent in service activities including, but not limited to: working with people, participating in community activities, cleaning and maintenance projects, serving in public schools or other community institutions, and other service activities, and in transportation to and from service work sites. As partial consideration of being allowed to participate in this activity with Blinn College, I hereby assume all risks involved in the service activities, acknowledge that workers compensation benefits are not extended to me in my capacity as server/volunteer, and hold Blinn College, its employees, officers, and Board of Trustees harmless.

I understand and acknowledge that the College is not affiliated with, nor does it have a right of control over the operations of, the Agency. The College's sole role is to facilitate placement of willing student enrollees with agencies who are willing to provide service learning opportunities. The College is not responsible for any errors, omissions, or negligence on the part of the Agency, its employees, directors, volunteers or Affiliates. I am further advised that the Agency may not maintain sufficient liability coverage to compensate an individual student for any harm experienced during the course of service at the Agency.
If you have questions about the existence or sufficiency of liability insurance coverage at your proposed service placement, please contact the specific agency directly. Any Student who objects to assignment to a service agency which the Student deems to possess insufficient insurance coverage may request assignment to a different agency, subject to available placement openings.

Legal guardian: I specifically grant this waiver of claims for myself and/or on behalf of my ward identified above and will hold harmless such institutions and individuals from any claims.

Important: In order to protect the persons working or residing at the community partner site, particularly if it is a school, nursing home or medical facility, I will refrain from attending the site if I am ill.
  Check one:* student parent legal guardian
Optional demographic information to tracking program diversity  
I identify as (mark all that apply):      
Black African Heritage Asian African-American  
Caucasian/Anglo Latino/Hispanic International Other
Age: under 18 25 to 35
  18 to 25 35 and older
Year: 1st year 2nd year
  3rd year 4th year
Gender: Male Major (may list undecided):
  Female


(Do not click "submit" if you are a student under 18 or a parent or legal guardian.
Instead, select "File" and "Print" at the top of your web browser. Sign below and return to instructor.)


Signature of Parent or Legal Guardian: _________________________________________________ (for printed version only)