Student Enrollment Form for Service Learning Experiences

Last Name:
First Name:
Student Middle Initial:
Home Street Address:
City:
State:
Zip Code:
Home phone:
Cell Phone:
email: (Required)
Student Identification Number:

Name of Emergency Contact Person:
Relationship to You
Home Street Address:
City:
State:
Zip Code:
Home phone:
Cell Phone:

Course Title and Number
Section Number
Course Instructor:

Agency Name

Yes ~ I have read the description of the service learning experience and I understand my participation in it.
Yes ~ I understand I am to furnish my own transportation to and from the service learning site.

I, , in consideration of the opportunity to participate in a service-learning experience as part of the fulfillment of the requirements for the course named above, acknowledge the risk of accident or injury inherent in working at an off-campus site. I understand that the location will not be under the control of the College. I agree that Prairie State College will not be responsible for any personal injury, including death, to me or damage to my property, unless negligently caused by employees of Prairie State College. I assume liability for and agree to indemnify and to hold the College and its employees harmless for all claims or damages caused, in whole or in part, by me and any negligent, intentional, or other act or omission on my part.

I agree to abide by all regulations, policies, and pocedures of Prairie State College and of any entity where I participate in the service-learning program.

I acknowledge that the service-learning experience in the above-named course does not create an employee/employer or independent contractor relationship with Prairie State college or with any entity where I am placed and that I will not receive, cannot accept or claim entitlement to any wages, benefits, workers' compensation, or any other form of compensation. I acknowledge that participation in service-learning program is wholly voluntary. I am above the age of 18 and I have read the above statement and agree to the conditions set forth herein. This release and hold harmless agreemend binds the members of my family and spouse, and my estate, heirs, administrators, personal representatives, assigns, and any other person entitled to act on my behalf. this agreement shall be construed under the laws of the State of Illinois without regard to its conflict of law provisions and jurisdiction and venue will be in cook county, Illinois. If any portion of this is held to be invalid, illegal, or unenforceable, the remaining portion shall be in full force and effect.

I have read this document before clicking on the submit button below and I agree that by clicking on " submit" I am stating that it is of my own free act and deed, intending to be bound by the promises I have made herein.

Call: (708) 709-3781
FAX: (708) 709-7743
email:Angela Winters-Harmon

By clicking the "submit" button I certify that the above information is true and correct to the best of my knowledge.

After you click on "submit" you will be directed back to this page. It is not necessary to click "submit" again.

Reset will clear all information entered.