Service-Learning / Volunteer Assumption of Risk, Release, and Hold Harmless Agreement
THIS IS A LEGAL DOCUMENT. READ IT CAREFULLY AND OBTAIN LEGAL ASSISTANCE IF YOU DO NOT UNDERSTAND IT.
The above-named EFSC student requests permission to participate in the Service-Learning / Volunteer experience(s) referenced
in the student’s Placement Confirmation form(s) on file with the Center for Service-Learning and Civic Engagement (hereinafter,
the “Experience”), and hereby acknowledges as to each Experience:
My participation in the Experience is strictly voluntary, and I am under no obligation by EFSC to participate; and
My participation in the Experience will require me to provide my own transportation to and from off-campus locations where
I will perform duties for and have regular interaction with persons who are not associated with or under the control or
supervision of EFSC; and
There are potential risks and hazards associated with the Experience and its related travel and duties, including but not
limited to, property damage, loss, illness, disease, or bodily and/or emotional injury, including death; and
Despite the potential risks and hazards associated with the Experience and its related travel and duties, I wish to proceed,
and freely accept and assume all risks and hazards that may arise from my participating in the Experience and that could
result in property damage, loss, illness, disease, bodily and/or emotional injury, or death, however caused.
Knowing these risks, and in consideration of the benefits to be derived from participating in the Experience, I, on behalf of myself
and my heirs, personal representatives, successors, and assigns, hereby release and hold harmless the District Board of Trustees
of Eastern Florida State College, Florida, its affiliated entities, and its trustees, officers, employees, agents, successors, and assigns
(“the College”) from any and all liability, claims, and causes of action for any and all property damage, loss, illness, disease, bodily
and/or emotional injury, or the consequences thereof, including death, resulting from or in any way connected with my
participation in the Experience, or my traveling to/from the Experience, or my engaging in any duties incident to the Experience,
whether caused by my actions or negligence, or the actions or negligence of the College, or any third parties, or otherwise.
SIGNATURE OF STUDENT
I have read and agree with the above, and further agree to abide by any and all local, State, and Federal laws and ordinances, as well
any and all EFSC and Community Partner policies and procedures at all times while participating in the Experience.
Signature: __________________________________________________________ Date: _____________________________
FERPA WAIVER AND EMERGENCY CONTACT INFORMATION
I understand that under the Family Educational Rights and Privacy Act (“FERPA”), EFSC is required to keep confidential various types
of student records. I also understand that in case of an emergency, certain people may want to know or should know about my
whereabouts or condition. For that reason, during the days and times of the Experience, I waive my FERPA rights as they relate to my
whereabouts and condition, and authorize EFSC to disclose in case of an emergency such information to:
Name: ____________________________________________________________ Relationship: ________________________
Phone: ______________________________________________ Email: ___________________________________________
Address: _____________________________________________ City: _____________________________ State: __________
FOR STUDENTS UNDER THE AGE OF 18
I am the parent or legal guardian of the above-named student. On behalf of myself and the above-named student, I agree to the
terms of this Service-Learning / Volunteer Assumption of Risk, Release, and Hold Harmless Agreement.
Parent Name/Legal Guardian: __________________________________________ Relationship: _______________________
Signature: __________________________________________________________ Date:______________________________
DISTRIBUTION: White (Student Copy) Yellow (Center for Service-Learning and Civic Engagement)
