List the course you are doing your service learning for. Students doing service that is not tied to a course, please type in Independent Study)
Write YOUR TEACHER'S First and Last NAME below.
(ex. Wing Cheung, Amanda Hill)
Community Organization Information
examples may be: Preschool assistant, classroom volunteer, food distribution, etc.
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 Palomar College, 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.