OFFICE OF COMMUNITY SERVICE LEARNING STUDENT REGISTRATION FORM

Students: Please complete the following information. For your convenience, in some boxes we have pull down choices. Please complete this form once you obtain ALL information required.

Questions with * means that the information is required in order to submit registration

Student Information

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Ex: 760-123-4567
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Ex: 760-123-4567
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Ex: jones001@cougars.csusm.edu
Emergency Contact

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Ex: 000-000-0000
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Course Information

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Ex: HD 101
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Ex: 10
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Required
Optional

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Fall
Spring
Summer

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Agency Organization
IF the organization in which you are doing your service is NOT on the OCSL database, ask for your instructor's approval and submit a Request to Add Organization form and provide the agency's information:http://www.csusm.edu/procurement/procurementservices/sfpaddorgform.html
Agency Information

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Site Supervisor Information

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Ex: 760-123-4567
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Ex: mysupervisor@agency.org
Job Description & Student Responsibilities

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Student Responsibilities
Please describe the responsibilties and duties you will have while serving at the site
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Goals, Objectives & Outcomes
Please describe in detail the goals, objectives and outcomes you'd like to receive while serving at this site. What knowledge, understandings, abilities and skills would you like to gain throught the experience?
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Student Demographics:

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Use of Photo/Essay Release
The Office of Community Service Learning photographs students working onsite and are published for educational and promotional purposes of the SL office only.
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I hereby give permission to the SL Office to publish photographs of me involved in service activities
I DO NOT want my photograph to be taken

Reflection Essays
The Office of Community Service Learning collects students essays for the annual edition of "Reflections", and they are used for educational and promotional purposes of the SL office only.
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I hereby give my permission to print my service learning essay in the annual edition of Reflections
I DO NOT want my service learning essay to be used

Submit Registration