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Service Learning Faculty Request Form

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  • Service Learning Faculty Request Form


(*) denotes required information.

   

Date of Submission

Course Starting Date

Date of Service-Learning Experience

Course/Section Number

Number of Credits

Faculty Name


Service-Learning Objectives

Placement Needs

Number of Students 

 
 
Suggested Placement Agency Contacts

 

Number of service hours students will complete

Objectives of the Experience

Send assignment directions/syllabus if available.

 
Learning Objectives for Student Participants
 
1.
 

2.

 

3.

 

4.

 
Service Objectives for Community Partners
 

1.

 

2.

 

3.

 

4.

   

Office Use Only

Placement Site    
Contact