Student Learning Plan

Please complete the following information. For your convenience, in some boxes we have pull down choices.  

NOTE: Enter the information correctly. Upon entering your campus user name, and clicking the submit button at the end of the form you will receive a confirmation sent to your email address. This confirmation is to be printed and signed by your instructor. If you do not receive the e-mail confirmation, it means that the information entered was wrong.

Make sure to complete this form once you obtain ALL information required such as site supervisor's name, email address, ect.

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

Section I: Student Data

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Campus e-mail preferred
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Section II: Learning Site

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After School Programs
Elder Care/Nursing Home Programs
Health Education
HIV/AIDS Services
Human Services
Substance Abuse
Teen Pregnancy/Parenting Skills
Tutoring & Child Literacy
Other


Section III: Course Information

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Ex: HD 101
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Service Objectives
Describe the responsibilities and duties you will have while serving at the site
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Learning Objectives:
Please describe in detail how your primary responsibilites support/further your course work and your course goals, objectives and outcomes. What knowledge, understandings, abilities and skills would you like to gain throught the experience?
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Ex: 10
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Required
Optional

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Fall
Spring
Summer

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Section IV: Student Demographics:

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Asian/Pacific Islander
Black/Non-Hispanic
Hispanic
Native American/Alaskan
White/Non-Hispanic
Other
Rather not Say

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Male
Female
Rather Not Say

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18-25
25-35
35-45
45-55
55-65
65+
Rather Not Say


Section V: Use of Photo/Essay Release
The Office of Community Service Learning photographs students working onsite and collects reflection essays for the annual edition of "Reflections¿ Booklet. They 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

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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