UHCL Day of Service Saturday, March 3, 2012 REGISTRATION FORM. Personal Information : Name:_______________________________________ Student ID# __________________________
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UHCL Day of Service Saturday, March 3, 2012REGISTRATION FORM
Personal Information:Name:_______________________________________ Student ID# __________________________
Phone #: _________________________ Email Address: ___________________________________Are you a:___ Current Student___ Alumni___ Staff___ Faculty ___ Community Member
School of Major:___ School of Education___ School of Human Sciences and Humanities___ School of Computer Science and Engineering____School of BusinessAre you a:___ Undergraduate___ Graduate ____ Post-Grad/Doctoral
Will you need help with transportation from UHCL to the service site? ___ Yes___ NoAre you willing to assist with transportation from UHCL to the service site? ___ Yes ___ No (If yes, please provide the Student Life Office with a copy of your Driver’s License and current auto insurance card.)
Please list any student organizations that you belong to: _____________________________________________________________________________________________________________________________________________
Service Projects:(Please only sign up for ONE project. If you are willing to consider another project in the event your first choice is full, please put a “2” by your second choice.)
__ Houston Area Women’s Center – 24th Annual Race Against Violence (6:30am – 11am)
___ Habitat for Humanity – Baytown (8am – 12pm)
___ Krause Children’s Center – First Healing Hearts Benefit (3pm – 8pm)
___ Houston Food Bank Group 1 (8am – 12pm)___ Houston Food Bank Group 2 (1pm – 4pm)
___ Moody Gardens – Spring Break Palm Beach Set-Up (open times)
___ Descendants of Olivewood, Inc. – Olivewood Cemetery (9am -12pm)
___ Interfaith Caring Ministries Bay Area Resale Shop (open times)___ Bibleway Fellowship Baptist Church ONEPowerful Movement (8am – 1pm)
You will receive a confirmation email with more details about the project.
PLEASE TURN THIS PACKET IN TO THE STUDENT LIFE OFFICE SSB 1.204.For more info about projects: www.uhcl.edu/slice and click on “Day of Service” link.
Authorization for Use of Photograph or Likeness
I, (printed name) __________________________________________, do hereby permit and authorize the University of Houston-Clear Lake, the University of Houston System and its components, employees, agents and other personnel who are acting on behalf of the system to use my photograph or other likeness for purposes related to the educational mission of the system, including publicity, marketing and promotion of the system and its components. I understand my photograph may be copied and distributed by means of various media, including publications, video presentation, television, news releases, mail outs, billboards or signs, brochures or Web sites.
I understand that, although the University of Houston-Clear Lake, the University of Houston System and its components will endeavor to use my photograph in accordance with standards of good judgment, the University of Houston-Clear Lake cannot guarantee that any further dissemination of my photograph or likeness will be subject to system supervision or control. Accordingly, I release the University of Houston-Clear Lake from any and all liability related to dissemination of my photograph or likeness.
I have read this document and understand its contents.
Signature of Subject (If subject is a minor child, a guardian Date
must sign this form and indicate relationship to child.)
City, State, ZIPE-mail Address
Signature of photographer, on behalf of the University of Date
RELEASE AND WAIVER OF LIABILITY FOR TRAVEL
The undersigned, who is participating in a university sponsored trip to: (Name of Service Project)_____________________________ for participation in UHCL Day of Service on Saturday, March 3, 2012 do hereby:
Release and forever discharge the University of Houston – Clear Lake and the University of Houston System, its members individually, and its officers, agents, and employees, of any and all claims, demands, rights and causes of action of whatever kind, arising from and by reason of any or all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, resulting from my participation or in any way connected with this trip.
SIGNED this __________ day of __________________, 2012.
Signature of Student Making Trip
Printed Name of Student Making Trip
Emergency Contact Person (Printed Name)
Emergency Contact Person (Phone Number(s))
One copy of this completed form will be carried by staff advisors on this trip and one copy will be left with staff at the university (Student Life Office).
Form No. OGCS9820
Form No. OGC-S-98-20
UNIVERSITY OF HOUSTON – CLEAR LAKE
RELEASE AND INDEMNIFICATION AGREEMENT FOR ADULT STUDENTS
STUDENT (Name and Address)INSTITUTION:
________University of Houston – Clear Lake_______________________2700 Bay Area Blvd.
______________________________________Houston, TX 77058-1098
DESCRIPTION OF ACTIVITY OR TRIP: UHCL Day of Service_______________________________________
LOCATION:(Name of Service Project)_______________________________________ DATE: Saturday, March 3, 2012
I, the above-named Student, am eighteen years of age or older and have voluntarily applied to participate in the above Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that may result in my illness, personal injury, or death, and I understand and appreciate the nature of such hazards and risks. I represent that I am physically able, with or without accommodation, to participate in the above-referenced Activity or Trip, am able to use the equipment and/or supplies associated with the Activity or Trip, and have obtained all required immunizations.
In consideration of my participation in the Activity or Trip, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release the above named Institution, its governing board, officers, employees, and representatives from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Activity or Trip, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Activity or Trip.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
Should I require emergency medical treatment as a result of accident or illness arising during the Activity or Trip, I consent to such treatment. I acknowledge that the University of Houston does not provide health and accident insurance for participants in the Activity or Trip and I agree to be financially responsible for any medical bills incurred as a result of emergency medical treatment. I acknowledge that I have been given the option to purchase insurance for the Activity or Trip through the University. I will notify University representatives in writing if I have medical conditions about which emergency medical personnel should be informed.
Signature of Student Signature of Witness
Date Signed Date Signed
Note: To request disability accommodations for this Activity or Trip, please contact [the Center for Students with Disabilities at least 10 days in advance of the Activity or Trip by calling (713) 743-5400 (voice); (713) 749-1527 (TTY); (713) 743-5396 (FAX).]
OGC Form No. S-98-20:
Approved for use as a Standard Agreement
by the University of Houston System Office of the
General Counsel 8/31/98Note: Modification of this Form requires approval of OGC