11333 Big Bend Road
St. Louis, MO 63122-5720
314-984-7500 • Fax: 314-984-7117
Individuals with speech or hearing impairments
may call via Relay Missouri by dialing 711.
RELEASE
Please fill in all blanks:
This is a legally-binding Release made by me, ___________________________, to the ST. LOUIS
COMMUNITY COLLEGE (“College”).
LET IT BE KNOWN, that the undersigned herein states that his/her name, voice and/or image is reflected
in the photograph(s), audio and/or audiovisual recordings to be used in publicity and/or news releases
and/or production of education materials, and that in consideration for ST. LOUIS COMMUNITY
COLLEGE publishing my name, voice, and/or image, the undersigned hereby authorizes ST. LOUIS
COMMUNITY COLLEGE and those acting pursuant to its authority to use my name, voice and/or image
without restrictions or limitations as deemed appropriate by ST. LOUIS COMMUNITY COLLEGE, and
does hereby and for his/her heirs, executors, administrators, successors and assigns expressly release, acquit
and forever discharge ST. LOUIS COMMUNITY COLLEGE, its agents, servants, officers, directors and
employees of and from any and all claims, actions, causes of action, demands, rights, damage, costs, loss of
service, expense and compensation whatsoever which the undersigned participant may have or which may
hereafter accrue on account of or in any way growing out of use of my name, voice, and/or image in
photographs, audio and/or audiovisual recordings.
The undersigned further agrees to indemnify and hold harmless ST. LOUIS COMMUNITY COLLEGE, its
governing Board and its agents, servants, officers, directors, and employees from each and every claim,
demand, loss, damage, or expense for any and all liability or damages resulting from the use of said
photograph(s), audio and/or audiovisual recordings that may in any way relate to his/her representation that
he/she is the person whose name, voice, and/or image is reflected therein.
The undersigned understands that this Release covers liability, claims and actions caused entirely or in part
by acts or failure to act of the College or its governing board, employees, or agents, including but not
limited to negligence, mistake, or failure to supervise by the College.
The undersigned further declares that no promise, inducement or agreement not herein expressed has been
made to the undersigned, and that the undersigned fully understands this agreement, and that this Release
contains the entire agreement between the parties hereto, and that the terms of this Release are contractual
and not a mere recital.
Participant:
________________________________________
Date: ______________________
Signature (Parent or Guardian must sign for a minor)
Address:
________________________________________
❐ student
________________________________________
❐ employee
Email:
________________________________________
Campus:
________________________________________
White/Media
Yellow/Community Relations
Program ____________________
Pink/Participant
400399
Service Learning Assumption of Risk and Release of Liability Form
I, _____________________ , a student of St. Louis Community College at ________________________
(referred to throughout the rest of this form as ''the College"), acknowledge that I freely and voluntarily
have registered for ____________________________________________(referred to throughout the rest
of this form as "the Course"), for the Semester of 20___, I understand that the term "College"
includes its governing board, employees, instructors, and agents. I understand that the Course includes offcampus activities ("Service Learning Activities") for which the College cannot exercise control and that the
Service Learning Activities will be conducted on my own time. I am at least 18 years of age and I
understand that if I have any questions regarding this Release of Liability Form I may have them answered
before signing it. I am also free to have the Form reviewed by an attorney before signing it. This Release of
Liability binds my heirs, executors, administrators, and assigns, as well as me.
I fully understand and agree that certain elements of the Course, including the Service Learning Activities,
are physically and emotionally demanding and that by participation in the Service Learning Activities in
locations not under the control of the College, there are risks of accidental or other physical or emotional
injury. These risks may include, but are not limited to, loss or damage to personal property, personal injury,
or death. I understand that in performing these activities on my own time, I am a server/volunteer for the
community agency and NOT a server/volunteer, employee, or agent of the College in any capacity. I
ACKNOWLEDGE THAT THE COLLEGE DOES NOT EXTEND WORKERS COMPENSATION
BENEFITS TO ME IN MY CAPACITY AS A SERVER/VOLUNTEER. I understand that I am solely
responsible for any medical costs I may incur as a result of my participation in Service Learning Activities
referred to me by the College.
I EXPRESSLY AGREE AND INTEND THAT MY PARTICIPATION IN THE SERVICE LEARNING
ACTIVITIES SHALL BE UNDERTAKEN AT MY OWN RISK AND THAT THE COLLEGE SHALL
NOT BE HELD LIABLE FOR ANY INJURIES, DAMAGES, OR CAUSES OF ACTION
WHATSOEVER THAT MAY ARISE OUT OF, OR IN CONNECTION WITH, MY PARTICIPATION
IN SERVICE LEARNING ACTIVITIES, INCLUDING TRAVEL TO OR FROM SERVICE LEARNING
ACTIVITIES AND OTHER CONNECTED ACTIVITIES, WHETHER FROM ACTS OF ACTIVE OR
PASSIVE NEGLIGENCE ON MY PART, THE PART OF THE COLLEGE, OR THE PART OF THIRD
PARTIES FOR ANY SUCH INJURIES, DAMAGES, OR CAUSES OF ACTION TO OR AGAINST
MYSELF OR THAT I MAY CAUSE TO A THIRD PARTY.
IN EXCHANGE FOR MY PARTICIPATION IN THIS COURSE, IT IS MY SPECIFIC AND EXPRESS
INTENT THAT IN THE EVENT THE COLLEGE SHOULD CAUSE, EITHER DIRECTLY OR
INDIRECTLY, LOSS OR DESTRUCTION OF PROPERTY, INJURY (INCLUDING DEATH),
LIABILITY, OR CLAIMS AGAINST ME AS A RESULT OF INTENTIONAL ACTIONS OR
NEGLIGENT CONDUCT, I WILL HOLD THE COLLEGE HARMLESS AND INDEMNIFY OR
DEFEND COLLEGE FROM ANY AND ALL OBLIGATIONS, LIABILITIES, CAUSES OF ACTION,
LAWSUITS, AND DAMAGES, INCLUDING LEGAL FEES, THAT RESULT FROM THE COLLEGE'S
INTENTIONAL ACTIONS OR NEGLIGENT CONDUCT.
The terms of this Release of Liability shall be governed by the laws of the State of Missouri. Should any
term or provision of this Release of Liability be found to be unenforceable, that shall not affect the
enforceability of the remaining terms and provisions of this Release of Liability. I agree that exclusive venue
for any dispute arising between the College and me involving this Release of Liability in any way shall be in
St. Louis County, Missouri.
Date
White/Media
________________________________________
Student/Participant Signature
Yellow/Community Relations
Pink/Participant