Student Assignment Form
The Center For Service Learning
7201 Rossville Boulevard
Baltimore, Maryland 21237
Social Science and Human Development
Building
L Building--Room 313A
Phone: 410-780-6409
Name (Please Print): ___________________________________
Instructor: _________________________________ Course Title:
_______________________
Number of Service Hours to Complete: ________
Assigned Service Site: ______________________________________________
Site Supervisor: __________________ Service Site Telephone: _____________
Site Address: _____________________________________________________
_____________________________________________________
Service Dates: ______________________________ Times:
__________________________
_______________________________Times:
__________________________
_______________________________Times:
__________________________
_______________________________Times:
__________________________
_______________________________Times:
__________________________
Additional Comments or special instructions:
_______________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Service Learning Assistant Coordinator: _____________________________
Date Assigned: _____________
Please Note: Students participating in service learning
activities are required to use this form as an official means of
reference regarding their assigned agency/organization site, dates and
times of their specific terms of service. In the event of questions
contact the Center for Service Learning at CCBC Essex,(410) 780-6409,
Division of Social Science and Human Development, Office: Room 313A.
Thank you for your cooperation.
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