I will devote approximately 8 hours per week toward completion of the service and learning objectives
listed in my Learning Agreement for a total of 120 service hours, effective from __________
to__________ (“learning activity”). I agree to complete any paperwork and orientations required by my
professor or site supervisor as part of this learning activity.
I understand and acknowledge that there are potential risks associated with this learning activity, some
of which may arise from (a) my assigned tasks and responsibilities, (b) the location of the learning
activity,(c) the physical characteristics of the Learning Site, (d) the amount and type of criminal activity
or hazardous materials at or near the location of the learning activity, (e) any travel associated with the
learning activity, (f) the time of day when I will be present at the Learning Site, (g) the criminal, mental
and social backgrounds of the individuals I will be working with or serving, and (h) the amount of
supervision I will receive. I further understand and acknowledge that my safety and wellbeing are
primarily dependent upon my acting responsibly to protect myself from personal injury, bodily injury or
Being aware of the risks inherent in this learning activity, I nonetheless voluntarily choose to
participate in this learning activity. I understand that I may stop participating if I believe the risks become
While participating in this learning activity, I will (a) exhibit professional, ethical and appropriate
behavior; (b) abide by the Learning Site’s rules and standards of conduct, including wearing any
required personal protective equipment; (c) participate in all required training; (d) complete all assigned
tasks and responsibilities in a timely and efficient manner; (e) request assistance if I am unsure how
to respond to a difficult or uncomfortable situation; (f) be punctual and notify the Learning Site if I
believe I will be late or absent; and (g) respect the privacy of the Learning Site’s clients.
While participating in this learning activity, I will not (a) report to the Learning Site under the influence
of drugs or alcohol; (b) give or loan money or other personal belongings to a client; (c) make promises
to a client I cannot keep; (d) give a client or representative a ride in my personal vehicle; (e) engage
in behavior that might be perceived as harassment of a client or Learning Site representative; (f)
engage in behavior that might be perceived as discriminating against an individual on the basis of their
age, race, gender, sexual orientation, mental capacity, or ethnicity; (g) engage in any type of business
with clients during the term of my placement; (h) disclose without permission the Learning Site’s
proprietary information, records or confidential information concerning its clients; or (i) enter into
personal relationships with a client or Learning Site representative during the term of my placement. I
understand that the Learning Site may dismiss me if I engage in any of these behaviors.
I agree to contact the University’s Director of CICE (657-278-7450) if I believe I have been
discriminated against, harassed or injured while engaged in this learning activity.
I understand and acknowledge that neither the University nor the Learning Site assumes any financial
responsibility in the event I am injured or become ill as a result of my participating in this learning
activity. I understand that I am personally responsible for paying any costs I may incur for the treatment
of any such injury or illness. I acknowledge that the University recommends that I carry health
I have read, understand and agree to comply with these guidelines.
Student Signature: Date: / /
Student Name (print)