Member Registration Form and Agreement School:

First Name

Female

English

Japanese

Korean

Mandarin

Spanish

____________________ Uof AStudent?

Name: __________________

Sex:

Cantonese

Last Name

Male

No

Graduate Studies

French

Alumni Undergrad

Date of Birth: _ _ _ _ / _ _ / _ _ First Language: _____________

Phone Number: _______________________________ ______________________________ Home

Cell

Email Address: _______________________________________________________________

Emergency Contact: ________________________ Contact Number: ___________________ How did you learn about SVCC? ____________________________________________________________________________ Disclaimer Student Volunteer Campus Community (SVCC), the Governors of the University of Alberta and their respective officers, directors, employees, volunteers, members, representatives and sponsors are not responsible for any injury, loss or damage of any kind sustained by any person or property while participating in SVCC activities. SVCC is a volunteer run student group and is not an accredited language school. Protection of Privacy The personal information requested on this form is collected under the authority of section 33 (c) of the Alberta freedom of information and protection of privacy and will be protected under part 2 of that act. It will be used for the purpose of implementing this registration. Direct any question about this collection to Raymond Tam, President, SVCC student groups. Acknowledgement I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT, and that I have executed this agreement voluntarily. 1. I acknowledge that the students of the University of Alberta are subject to the University of Alberta's Code of Student Behaviour and that I represent the University of Alberta. I, therefore, agree to conduct myself accordingly at all times while as a member of SVCC. 2. I agree to follow all rules, guidelines, health and safety regulation, laws, the SVCC Member Code of Conduct and Refund Policy and other policies and procedures of SVCC, the University or other officials or bodies with jurisdictional authority. Failure to comply could/can result in my being removed/dismissed from SVCC or any event of SVCC. 3. This Agreement shall be effective and binding upon myself, my heirs, next of kin, executors, administrators, assigns and representatives in the event of my death or incapacity. _______________________________ Member’s Signature

Email: [email protected]

_______________________________ Witness’s Signature

________________________ Date (MM/DD/YY)

Website: www.svcclanguages.org