Student Placement Request for Non-Contracted Sites

STUDENTS SHOULD ONLY SUBMIT THIS FORM AFTER MEETING WITH AND CONFIRMING PLACEMENT WITH THE AGENCY OR ORGANIZATION.

All students engaged in off-campus service projects for credit and/or academic courses at locations not listed on this site must complete this Student Placement Request for Non-Contracted Sites, including fieldwork, internship, field studies, applied, and service learning courses, or courses with an assigned community project. Students who do not successfully complete the placement process or submit this form cannot take part in the learning/service activity. These students must contact their instructors. To successfully submit this form, students must acknowledge they understand and agree to the terms, and submit with signature.

Student Identification Information
this is the agency or organization representative who has approved your service experience
The Student agrees to act in a responsible manner while representing California State University and abide by all rules and regulations that govern the site in which he/she has been placed. For more information on student conduct requirements go to http://www20.csueastbay.edu/students/campus-life/student-life/sdja/student-conduct.html.
*Food Serving & Preparation-Risk includes but not limited to: Handling kitchen items, cuts, burns, lifting *Landscaping/Gardening/Habitat Restoration - Risk includes but not limited to: Sun exposure, cuts, lifting, falls, environmental exposure such as heat, moisture, and other outdoor elements *Building & Repair- Risk includes but not limited to: Sun exposure, cuts, bruises, chemical exposure such as paint *Event Set-Up- Risk includes but not limited to: Lifting, cuts, bruises Knowing, understanding and in full appreciating the potential of risks, I hereby expressly, voluntarily and willingly assume all risks and dangers associated with my participation in this activity up to and including death. Some of the risks and dangers are listed here. I understand this list is not all inclusive and may not cover all events offered.
*Travel to and from home and off campus learning experience, activity, or meeting *food poisoning *theft *car accident *pedestrian accident *tripping, flipping, falling, etc Knowing, understanding and in full appreciating the potential of risks, I hereby expressly, voluntarily and willingly assume all risks and dangers associated with my participation in this activity up to and including death. Some of the risks and dangers are listed here. I understand this list is not all inclusive and may not cover all events offered.
Please be aware that medical coverage and services provided by the Student Health Services of CSU East Bay are limited. Medical services not available from the CSU East Bay Student health Services would need to be provided by a separate medical plan such as a family health plan. Students should plan to use their personal medical insurance as a primary medical coverage payment if an accident or injury occurs.
I have read this informed consent, waiver and release and understand the terms used in it and their legal significance. This informed consent, waiver and release is freely and voluntarily given with the understanding that the right to legal recourse against the State is knowingly given up in return for allowing my participation in the activity. My signature on this document is intended to bind and not only myself but also my successors, heirs, representatives, administrators, and assignees. I am 18 years or older. I understand that by providing an electronic signature, I have read, understood and am accepting this waiver.


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