Membership Application

Submit this form to become a member. Be sure to complete all parts including attached Release and Indemnification and Media Release forms. To access this form electronically, visit the MVC link on the utep.edu/cce page.

/ Student Information
Name: / Today’s Date:
Email: / Cell Number:
UTEP ID #: / Available to text: Yes No
UTEP Username:
(ex. )
Major: Minor: Cumulative GPA:
(if known) (if applicable)
Status:
Full-time Part-time / Classification:
Undergraduate Graduate
/ Tell us more about you…
In a short paragraph describe what type of volunteering experience you would like to participate in?
(ex: animal shelters, events, school activities…)
Describe previous community service you have completed on or off of campus (if any):
In a short paragraph tell us what makes you a “dependable person”.
Please tell us a little about yourself, your academic career, and your motivation to get involved with your community. We will utilize this information to create a brief “Student Bio” on the MVC webpage:

Please submit this application, along with a completed Release and Indemnification Agreement Form and Media Release Waiver (below) to the Center for Civic Engagement via email at or in person (Benedict Hall Rm. 101).

The CCE will email you an application receipt confirmation along with instructions for the next steps.

Thank you for your interest in the Miner Volunteer Corps Program!

RELEASE AND INDEMNIFICATION AGREEMENT

(Adult Student Participant)

Participant: (Name and Address) University:

Name: The University of Texas at El Paso

Student ID: Department:

Phone: Center for Civic Engagement

Email:

Description of Activity or Trip: Participate in activities related to Miner Volunteer Corps Program.

Location: Various Date(s): Fall 2014-Spring 2015

I, the above named Student, am eighteen years of age or older and have voluntarily applied to participate in the above-referenced 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.

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 University of Texas at El Paso, its governing board, officers, employees and representatives from any 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 University, its

governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the University 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 AND FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

Signature of Student


Date:

THE UNIVERSITY OF TEXAS AT EL PASO

UNIVERSITY COMMUNICATIONS

PHOTOGRAPHIC CONSENT AND RELEASE FORM

I hereby authorize The University of Texas at El Paso, Office of University Communications, and those acting pursuant to its authority to:

(a) Record my likeness and voice on a video, audio, photographic, digital, electronic or, any other medium.

(b) Use my name in connection with these recordings.

(c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/WWW) these recordings, in whole or in part, without restrictions or limitations for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including educational, promotional or advertising efforts.

I release the University and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. This release is executed gratuitously and/or for any self-satisfaction which I may derive from any publication or programs in which my likeness or voice will appear. I understand that all such recordings, in whatever medium, shall remain the property of the University.

I HAVE READ AND F ULLY UNDERSTAND THE TERMS OF THIS RELEASE.

Name:
Address:
Street
City State Zip
Phone:
Signature / Date
Parent/Guardian Signature (if under 18):
Signature / Date