STUDENT REGISTRATION FORM

Students: Please complete the following information. For your convenience, in some boxes we have pull down choices. Please fill out all boxes.

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

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MM/DD/YY
Student Information

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*
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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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Ex: 000-000-0000
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Course Information

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Ex: Introduction to Human Development
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Ex: HD 101
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Yes
No
Not sure

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Ex: 10
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Yes
Not sure

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Agency Information

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*
Non-Profit
Not sure





Agency Supervisor Information

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*
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Ex: 760-123-4567
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Ex: mysupervisor@agency.org
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OPTIONAL: Student Demographics: (Requested for federal reporting purposes, yet not required)




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.

*
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

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.

*
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
Not applicable

Submit