Service Learning Student

1.

Your Name:

2.

Why are you participating in this Service Learning Volunteer Opportunity?

(Select all that apply.)

For a school class

Required service hours for school

For senior/culminating/capstone project

Environment

Human Services

Public Safety

Education

Homeland Security

Fun or personal interest

For interest projects, badges, achievement awards in scouts, 4H, YMCA, for example.

Career/Job interest and experience

Community involvement

3.

Teacher:

4.

Name of class

5.

Teacher/Mentor/Coach:

6.

Name of Youth Organization

7.

Address

8.

Zip Code

9.

Name of Adult Leader or Contact

10.

School (K-12, College, or University) Name

11.

School District

12.

Student ID Number:

13.

Do you have a service hour requirement for graduation?

Yes

No

14.

Email Address:

15.

Home Address:

16.

Zip Code:

17.

Birth Date:

18.

Grade in School:

Kindergarten - 3rd grade

4th-6th grade

7th-9th grade

10th-12th grade

13-20

19.

Gender

Male

Female

20.

How do you describe yourself?

(Select all that apply.)

Caucasian/White

Asian-American

African-American/Black

Native-American

Hispanic/Latino/a

Other:

21.

How many hours did you watch television yesterday?

22.

Minutes

23.

What are your favorite television programs?

(Provide three responses.)

24.

How many hours did you spend using a computer yesterday?

25.

Minutes:

26.

Computer Activities:

(Select all that apply.)

Doing homework

Chat rooms and instant messaging

Simulation/Role playing games online

Online research

Other video/computer games

27.

Do you belong to a club, team, or association (for example, teams, dance club, church group)?

(Select all that apply.)

sports team

church/synagogue/mosque group

scouts, 4H, YMCA, Campfire, etc.

community center

Other:

28.

Have you ever done service learning before:

Yes

No

29.

Do you have a paying job?

Yes

No

30.

If yes, how many hours did you work for money last week?

31.

Minutes:

32.

Where do you get news about events in your community, city, world?

(Select all that apply.)

Television

Radio Stations

Newspaper

Internet

Friends

Other:

33.

Service Learning project title:

34.

Project Description:

35.

Sponsoring Agency Name:

36.

Contact Name:

37.

Address:

38.

Phone:

39.

Email:

40.

Service Site Name:

41.

Service Site Contact Name:

42.

Address:

43.

Phone:

44.

Email:

45.

Number of hours served:

46.

Start Date:

47.

End Date:

48.

School Period:

(Select all that apply.)

1st Semester

2nd Semester

Summer Break

Winter Break

Spring Break

Fall Qtr

Winter Qtr

Spring Qtr

Summer Qtr

49.

Number of people served:

Low Socio-Economic Level

Medium Socio-Economic Level

High

Disabled

ESL

Homeless

57.

Ethnicity of populations served

(Select all that apply.)

Caucasian/White

Asian-American

African-American/Black

Native-American

Hispanic/Latino/a

Other:

0

1-5

6-12

13-25

26-50

51-100

>100

64.

Other:

65.

Communication (2008)

(Select all that apply.)

Public speaking skills

Writing

Interpersonal communication

Working in a team

66.

Quantitative and Scientific Reasoning (2009)

(Select all that apply.)

ID problem

Research/evaluate solutions

Data collection and analysis

Implement solutions

67.

Democracy, Diversity, and Community Stewardship (2010)

(Select all that apply.)

Project issue laws and policy

Builds tolerance and appreciation of racial, ethnic, economic, environmental, and other areas of diversity.

Democratic process: dialogue for information and discussion leading to decision making.

Project issue advocacy

68.

Other

(Select all that apply.)

Career Awareness and Life Skills (2011)

The Arts (2012)

69.

Essential Question/Issue of this service learning project

1 = least impact

2

3

4

5 = greatest impact

74.

Your Reflections: