Course Department and Number (ex. CHDV 115, SOC 100) *
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)
Your TEACHER'S NAME- Put your professor's First and Last Name ONLY *
Write YOUR TEACHER'S First and Last NAME below.
(ex. Wing Cheung, Amanda Hill)
Program Name and or Volunteer Role *
examples may be: Preschool assistant, classroom volunteer, food distribution, etc.
Hold Harmless Agreement/Waiver of Liability *
I agree to participate in a service activity and waive Palomar College District (District) liability as set forth in this declaration for said participation.
To the fullest extent permitted by law, I indemnify, defend, and hold harmless the District, its officers, agents, volunteers, and employees from all claims, suits, or losses and expenses, including but not limited to attorney fees, arising out of my participation in the ACTIVITY other than acts of gross negligence by the District, its officers, employees, and /or agents. This includes, but is not limited to, claims, damages, losses and expenses arising from injury to, loss of, theft of or unauthorized access to personally identifiable information or documents containing such information, as most broadly defined under state or federal law; or any actual or alleged failure to comply with any provision of law. However, I will not be obligated to indemnify an indemnified party for liability due to willful misconduct, active negligence, or sole negligence for which that indemnified party is legally responsible. 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. In consideration of my participation in the Service Learning event, activity, class, I hereby accept all risk to my health and of my injury or death that may result from such participation.
I understand that 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.
In signing this Hold Harmless/Waiver of Liability, I acknowledge that I have read it, understand its significance and am signing voluntarily of my own free will. I certify that I am at least 18 years of age, and that if I am under 18 of age my parent/legal guardian has signed this form on my behalf.