STUDENT INFORMATION FORM

The Center For Service Learning

CCBC Essex Campus
7201 Rossville Boulevard, Baltimore, Maryland 21237
Division of Business,Social Science,Health and Wellness L Building - Room 313A
Phone: 410-780-6409

E-mail: tgordon@ccbcmd.edu

Name: ___________________________________

Mailing address: ________________________________

City, State, and Zip Code:_______________________________ Phone: (Home)___________

Course Title: ________________________ Section: ______
 
Email: ___________________

Instructor: ____________________
 
Phone: (Office)_____________

Course Days: _________ Course Time: _____________

Times I am available to complete service

Additional Comments:________________________________________

____________________________________________________________

Required Hours to complete assignment:_____
Please list four (4) sites by numbers in order of preference:   

#1_________________________________________  
 
#2_________________________________________ 

#3_________________________________________  
 

Please note the following: In order to effectively place students in their service learning situations, it is understood that it is the responsibility of the student to contact the Center for Service Learning with any and/or all changes to the information listed above.  It is also the responsibility of the student to bring to the attention of the Center for Service Learning, not their instructor, any all concerns or questions about the given assignment and its terms of service.  The Center for Service Learning will consult the proper parties, academic and otherwise, if necessary.  By signing below, you agree to these terms.

Signature:____________________________    Date:____________                                                                                   

FOR OFFICE USE ONLY                                       

Student assigned to site:______________________________

Date(s) Assigned:____________
 
Time(s):___________

Student contacted by:______________________________Date:____________

Comments:____________________________________________________

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