Missouri State University
Citizenship and Service-Learning

COMPONENT Student Online Information and Releases

Campus

For Springfield Service-Learning Students Only

Counties You Are Available To Work In

(This should be the designate course you are currently enrolled in)

For West Plains Service-Learning Students Only

Counties You Are Available To Work In

FOR ALL SERVICE-LEARNING STUDENTS

Do you own a car?
PHOTOGRAPHIC RELEASE

I hereby irrevocably consent to and authorize the use by Missouri State University, its officers and employees, ("University") of my image, voice, and/or likeness as follows: The University shall have the right to photograph, publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display, or otherwise use or reuse my image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed in University products or services, as long as there is no intent to use the image, voice, and/or likeness in a disparaging manner. University may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or nonprofit. I acknowledge receipt of good and valuable consideration in exchange for this Release, which may simply be the opportunity to present the University in its promotional and advertising materials as described above.

PUBLICATION PERMISSION

I hereby grant Missouri State University permission to copy, print, and distribute my service-learning reflection assignment and/or evaluation comments (the "work") and to incorporate the work, in whole or in part, into the Citizenship and Service-Learning ("CASL") Annual Report, web site, Celebration program, and/or other promotional materials. I grant Missouri State University the right to edit the work for spelling, grammatical, or sentence structure errors.

CONFIDENTIALITY, CONDUCT AND LIABILITY RELEASE

CONFIDENTIALITY                                                                                                                                                                          As a service-learner, you may share in privileged information. You may learn information about clients or patients which is covered by rules of confidentiality. Speak to your supervisor to discuss how the obligations of confidentiality may apply to you. Do not reveal or discuss information about clients or patients without permission of the professionals for whom you are working.

CONDUCT                                                                                                                                                                                      You are expected to maintain professional conduct at all times as you are not only representing yourself, but representing Missouri State University, as well. Additionally, should you observe or hear of activities that are legally or morally questionable, you have a responsibility to report those activities to your Community Partner supervisor and your course instructor.

LIABILITY                                                                                                                                                                                             I acknowledge that student health insurance may be purchased and that I can contact Taylor Health at 836-4000 for additional information. Some community partners may require a student to carry liability insurance. If liability insurance is required, your community partner, the Citizenship and Service-Learning office, or your instructor will advise you. If you are conducting research with human subjects, the University requires certain guidelines to be met. Please contact your instructor for the requirements pertaining to research.

 

Have you ever been convicted of a crime other than a traffic offense, or are any criminal charges pending against you, or have you been dismissed/suspended form another college or university for disciplinary reasons?