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: _________________________________
Circle the number that most accurately indicates your opinion
regarding the statements below
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: ___________________________
Approx. # of service hours to be completed: __________
Duties to be performed: ____________________________________________________________________
Site Supervisor’s Signature
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.