Application Form
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