The Center for Service Learning



The Center For Service Learning

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


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:   



Signature:____________________________    Date:____________                                                                                   

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