GAVILAN COLLEGE SERVICE LEARNING PLAN

Student Name:

Date:

Address:

Phone #

Email:

Course Instructor:

Semester/Quarter:

Agency/Site:

E-Mail:

Site Supervisor:

Phone #:

Address:

Approximate # of Hours

Beg. Date:

End Date:

Learning Objectives: What are the learning objectives of this service experience. (Note: Instructor should fill out)

Service Objectives: Identify and describe the nature of the service activities in which you will be engaged. The service objectives should be designed to help you work toward your learning objectives. (Note: Student should fill out this section after securing a service assignment.)

The Site Supervisor:

Agrees to guide this student’s work and to submit a brief initial and a final student evaluation in a timely manner.

Agrees to discuss any concerns about the service learner’s performance with him/her directly, and with the course supervisor, staff member or other appropriate College personnel as necessary.

Agrees to hold the Gavilan Community College District, its employees and agents, free and harmless from any claims and causes of action resulting from our voluntary participation in this program. We also agree to provide general work site orientation, supervision and make every reasonable effort to provide a safe working environment. We understand that we are accepting the student as a volunteer, that we are not responsible for providing wages, but agree to assist Gavilan College by certifying that the student satisfactorily completed the minimum hours of community service required by the service learning course.

The community-based organization shall be responsible for damages caused by the negligence of its directors, officers, agents, employees and duly authorized volunteers occurring in the performance of this agreement. Gavilan College shall be responsible for damages caused by the negligence of its directors, officers, employees and duly authorized volunteers occurring in the performance of this agreement. It is the intention of the community-based organization and the College that the provision of this paragraph be interpreted to impose on each party responsibility for the negligence of their respective directors, officers, employees and duly authorized volunteers. The College does not provide Worker’s Compensation Insurance for students in these courses Student is not permitted to drive a vehicle to perform duties for the CBO. Please note, the College does not provide auto liability coverage for students and students are not covered by workers compensation while driving to or from their chosen site.

Site Supervisor Signature:

Date:

(Note to Site Supervisor: If you are aware of specific and/or considerable risk factors are present at this agency and/or placement, it is advisable to list them here.)

1.

2.

The Student agrees to abide by the following Guidelines and Limitations

Limitations

* If you feel that your rights have been or may be violated, or that any of the above stated limitations have been violated please contact the site supervisor and/or instructor.

The Student:

Agrees to act in a responsible manner while representing Gavilan College at the service learning placement site, and abide by all rules and regulations that govern the site in which he/she has been placed.

Understands the connection between the service-learning course, and the service and learning objectives to be fulfilled at the service site.

Has or will participate in an in-class orientation on Service Learning, and has or will read the above stated guidelines and limitations; understands his/her role as a service-learning student in working with the community partner.

Understands and acknowledges the risks involved with this service placement, and enters into this service-learning placement fully informed and aware. (Note to Faculty: If you are aware of specific and/or considerable risk factors are present at this agency and/or placement, it is advisable to list them here.)

1.

2.

Agrees to devote a total of ______ hours during the _______________semester in order to fulfill the service objectives described above.

Agree to complete any forms, evaluations or other paperwork required by either the course or the site supervisor.

I have read and understand the entire learning plan.

Student Signature:

Date:

Faculty/Course Supervisor:

I have examined and approved this learning plan.

Faculty/Course Supervisor Signature:

Date: