Service Learning Student Proposal Form

Are you doing Service Learning as part of one of the below programs?

Clubs

What Club/Org are you representing?

Officer Name

Officer Phone Number

Officer Email

Advisor Name

Advisor Email

Advisor Phone Number

Number of Club Members Participating

Honors & Independent SL

Student Name

MEID

Student Email

Student Phone Number

Proposed Host Agency

Contact Name

Contact Email

Contact Phone

Address of Service Learning

Proposed Start Date

Proposed End Date

Targeted Hours to Work

Detailed Description of Service Learning Project