Service Learning

Online Form for Student Registration

Student Information

First Name
Last Name
Mailing Address
City
Zip Code
Home Telephone #
Work/Cell Phone #
Email

Emergency Contact

Emergency Contact Name
Emergency Telephone #
Emergency Work/Cell Phone #
Relationship to Student

Course Information

Course Name
Course Number
Instructor Name
Instructor Email
Total Hours Required
Semester
Year

Agency Information

Community Organization

Agency Supervisor Information

Supervisor's Name
Supervisor's Title
Supervisor's phone #
Supervisor's E-mail
Program/Project Name
Student Position Title
Start Date of Service
End Date of Service
Year

Please take a moment to answer these questions:

Description of responsibilities
Desired Learning Goals/Objectives/Outcomes: (Knowledge, understanding, abilities and/or perhaps skill to be gained through the experience).

OPTIONAL: Student Demographics: (Requested for federal reporting purposes, yet not required)

Race/Ethnicity
Gender
Age

Use a Photo/Essay Release

Service Learning photographs students working onsite for educational and promotional purposes of the Service Learning office only.

Do you give permission to be photographed?

I give permission to be photographed.
I DO NOT want my photograph to be taken.

Service Learning collects students essays for educational and promotional purposes of the Service Learning office only.

Do you give permission to use your essays/reflections?

I give my permission to print my service learning essay.
I DO NOT want my service learning essay to be used.