The Center for Service Learning

 
 
 

STUDENT INFORMATION FORM

The Center For Service Learning

CCBC Essex Campus
7201 Rossville Boulevard, Baltimore, Maryland 21237
School of Wellness, Education, Behavorial and Social Sciences -BESS 313A
Phone:443-840-1409

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

Learning hours:
Mon.  Tues. Weds. Thurs. Fri. Sat. Sun. 
             
             

Additional Comments:________________________________________

____________________________________________________________

Required Hours to complete assignment:_____
Please list three (3) sites by numbers in order of preference:   

#1_________________________________________  
 
#2_________________________________________ 

#3_________________________________________  
 

Signature:____________________________    Date:____________                                                                                   

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