Center for Civic Engagement
Bristol Community College
Leadership Application
Semester ___________
Page 1 of 2
No later than the 4
th
week of class, send this completed application to the Civic Engagement Coordinator in L117 at the Fall
River Campus for approval. Service Records for approved projects are due by the 11
th
week of class.
I. P
ROJECT
I
NFORMATION
Course Information (if project is course-related; otherwise, skip this section)
:
Course ID (ex. SOC 101)
Section (ex: A01)
CRN (ex. 14338)
S-L Professor
E-Mail
Student Information:
Student Name (Last, First, MI)
Address (Street, City, State, Zip)
Student ID
E-Mail
Cell Phone
Home Phone
Community Partner Information:
Organization
Address (Street, City, State, Zip)
Supervisor’s Name
Supervisor’s Title
Phone
E-Mail
Proposed Leadership Project:
Project Description: (Brief description of the Community Service project to be performed by the group of BCC students or peers you will
recruit, help supervise, mentor and lead)
Projected Start Date
Projected End Date
Mutual Understanding:
The undersigned student agrees to maintain contact with his/her BCC or Community Partner Supervisor and complete the project. If the
leadership role is connected to an academic course, the undersigned student also agrees to complete a reflection assignment
documenting the project, his/her personal growth in community leadership skills and commitment to future community service. The
professor of the course for which the service was performed will complete a Credit Verification form to verify completion of the reflection
assignment for a course. The student leading a project during the Spring semester must complete the Community Service Record by April
15
th
in order to receive a red cord at the Civic Engagement Recognition Breakfast and be publicly recognized at graduation that year.
AGREED BY:
BCC/COMMUNITY PARTNER SUPERVISOR
Signature Date
STUDENT LEADER
Signature Date
STUDENT‘S PROFESSOR (if course-related)
Signature Date
CIVIC ENGAGEMENT COORDINATOR
Signature Date
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Center for Civic Engagement
Bristol Community College
Page 2 of 2
II. A
CKNOWLEDGEMENT OF
R
ISK AND
C
ONSENT
/W
AIVER OF
L
IABILITY
To be read and completed by the student or, if student is under 18 years of age, by a parent or legal guardian:
I acknowledge that I am seeking to participate in the voluntary Leadership activity (“activity”) described on page 1 of this contract.
I further state that I am at least eighteen (18) years of age, fully competent to sign this Agreement, and am voluntarily seeking to
participate in this activity (or in the case of students under the age of 18, I further state that I am the parent or legal guardian of the student
identified below and am legally authorized to sign this form on behalf of the student who is voluntarily seeking to participate in this activity).
I understand that by signing this document I am representing that I understand all its terms and conditions and fully intend to be bound by
the same. I also understand that I may wish to consult with an attorney prior to signing this document.
I acknowledge that there may be certain dangers, hazards, and risks associated with my participation in this activity. I further
acknowledge and understand that all risks cannot be prevented. If there are physical risks associated with this activity, I have consulted
with my physician and/or health care provider to discuss whether my participation in the activity is appropriate given my current physical
and mental health. Accordingly, I represent that I am physically and mentally able, with or without accommodation, to participate in this
activity, and am capable of using the equipment, if any, associated therewith.
On behalf of myself and my family (including legal guardians) I agree to assume all the risks and responsibilities surrounding my participation
in this activity, and agree to release from liability and waive any legal action against Bristol Community College, its governing board,
officers, agents, and employees (the parties), for personal injury, death, or property damage suffered by me while participating in this
activity or while in transit to or from the premises where the activity is being conducted.
I understand and agree that the College may not provide or have medical services or personnel available at the location of the activity or
on its campus. Therefore, should I require emergency medical treatment as a result of an accident or illness arising during this activity, I
consent to such treatment. Further, I acknowledge that the College does not provide activity participants with health or accident
insurance and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment provided.
Further, I agree to comply with all rules and regulations included in the College’s Student Handbook and all other rules as set forth by the
College personnel during the activity.
I agree that this document shall be construed in accordance with the laws of the Commonwealth of Massachusetts. If any term or
provision of this document shall be held illegal or unenforceable, the remaining terms and provisions shall remain in full force and effect.
Student Signature
(If under 18 years of age, parent or legal guardian signature)
Date
In case of an emergency, please contact:
Emergency Contact Name& Relationship to Student Emergency Contact Number
III. M
EDIA AND
P
HOTO
R
ELEASE
I give permission, without restriction, to Bristol Community College to (check all that apply):
Photograph me
Videotape me
Audio record me
Quote me
Use a copy of my writing
I hereby consent, for any and all purposes, to reproduction and/or use of the media noted above by Bristol Community College in any form
and in any medium, including advertising, display, or any other use. I hereby release Bristol Community College, the Commonwealth of
Massachusetts, and their employees and agents, from and against any liability, including liability for negligence, arising out of or in any way
connected to Bristol Community College’s use of the materials noted above.
S-L Student Signature
(If under 18 years of age, parent or legal guardian signature)
Date
click to sign
signature
click to edit
click to sign
signature
click to edit