This is a printable agreement form. Use the Print button to print and complete it by hand.
Student Service Learning Agreement
Michelle McGehee, michelle.mcgehee@blinn.edu, 979-209-8991
www.blinn.edu/servicelearning/
Student Information
Student’s Name (Please Print)
Student’s ID Number
Student’s Address
Home Phone
City, State, Zip
Other Phone
Email Address
Academic Period
Session
Fall Spring Summer
Course Name / Faculty Teaching Class
Emergency Contact Person
Telephone
Community Partner (Agency or Organization)
Telephone
Community Partner Supervisor’s Name
Telephone (if different)
Student Agreement
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 no, check here
Assumption of Risk Statement
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.
Signatures
Check one:
student parent legal guardian
Name (please print)
Signature
Date
College Representative
Joyce Langenegger
Executive Director of Academic Success
Date
Note: Either a fully executed electronic or physical version of this form must be on file prior to the commencement of the service learning project.
Optional Demographic Information
Optional demographic information is collected in order to track program diversity.
I identify as (mark all that apply):
Asian Black/African Heritage Black/African-American
Latino/Hispanic Caucasian/Anglo International Other:
Age:
under 18 18–25 25–35 35 & older
Major
(If uncertain, please indicate.)
Year:
1st year 2nd year 3rd year 4th year Other
Gender:
Male Female