Student name:______________________________________________________

Student address:____________________________________________________

Cell phone ___________________ Home phone________________________

Email, printed neatly: _________________________________________________

Course in which Service Learning is required: ______________________________

Faculty overseeing Service Learning experience: ____________________________

Student’s academic major: ______________________________________________

Number of hours required: _________ Deadline for completion:_______________

Languages student speaks: _________________________________________________

Availability: ___________________________________________________________

_____________________________________________________________________

Past service experience:

Please mark the following with I if it is an interest and S if you have the skill. Some may be blank if you have neither, some may have both:

_____tutoring _____direct service to clients in need
_____website work _____marketing and promotion
_____surveys and polls _____historical research
_____work with children _____work with seniors
_____art club or group _____music club or group
_____writing _____teaching a skill—which?
_____other:

I have been fingerprinted in California: Yes No

I have a current TB test: Yes No

In case of emergency, my contacts are:
Name, relationship, and phone numbers