Service Learning

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Volunteer Program | Service-Learning | Student Development

SERVICE-LEARNING APPLICATION
AND PROJECT AGREEMENT FORM

 

* = Required Field
 
Student's First Name:* Last Name:*
Student's ID Number:*    
Street Address:*
City:* Zip Code:*
E-Mail Phone Number*

The following information requested will provide the Service-Learning Center with valuable information to help further develop the Service-Learning Program at College of the Canyons. No personal information will be given to any third party.
Current Service-Learning Course:

Instructor's Last Name:*

5-digit course code:*
Course number and name:*
Number of hours required to complete this project is .
Community Agency Information
Please select two community agencies from the approved list you would be interested in working with to complete your service-learning project.

Please use this link to see which agencies have been approved by your instructor:
Faculty

First Choice:*  
Second Choice:  
Do you have a source of transportation?  Yes No
Student Data:
Date of Birth (Ex. 01/01/83)*

Gender

 Female Male
Ethnic Identification:
African American American Indian/Alaskan Native
White/Caucasian Non-Latino/Hispanic Filipino

Asian

Latino/Hispanic

Pacific Islander
Asian Indian Chinese Mexican, Chicano Guamanian
Cambodian Japanese Mexican American Hawaiian
Korean Laotian Central American Samoan
Vietnamese Other Asian South American Other Pacific Islander
Other Latino/Hispanic
Decline to State Other Non-White
Units enrolled in this semester:    
Units completed to date:     
Overall g.p.a. 
Please check one: *
I plan to transfer/graduate at the end of this semester
I plan on continuing my education at College of the Canyons next semester
Expected transfer/graduation date:
Academic Major:      Career Goals:
Languages you speak other than English:
Do you have any previous service or volunteer experience? * Yes     No
If yes, how many different agencies?
If yes, (approximately) how many total hours?
List agencies you have volunteered for in the past:
 

By clicking the submit button below, I agree to the terms of this agreement, and to complete the required assignments.

I will conduct myself in a professional manner with respect for others, and abide by all College regulations as outlined in the Student Conduct Code.
     

 

 

 

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College of the Canyons

Valencia campus:

(661) 259-7800

• 26455 Rockwell Canyon Road, Santa Clarita, CA 91355

Canyon Country campus:

(661) 362-3800

• 17200 Sierra Highway, Santa Clarita, CA 91351


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