24-25 Service Learning Registration

* indicates a required field

General Information

Students should work with their instructor to establish a relevant Service Learning host site. If a student needs assistance in finding a host site, please contact the Center for Student Careers and Employment at careercenter@sanjuancollege.edu.

Service Learning involves strengthening sites in the community through collaboration by using educational assessment, analytic reflection, and civic responsibility to apply academic connections. Students in service learning engage in process that includes pre-reflection, research, reflection and presentation.

First Name

Last Name

Student Information

First Name

Last Name

Phone Number

Student ID

Major

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to Student

Student Responsibilities

Adhere to planned placement schedule. Be punctual and conscientious in attendance for the duration of service learning placement. Maintain regular contact with field supervisor. Notify supervisor in advance if unable to participate as scheduled.

Arrange own transportation to and from service learning activities OR have internet capability for Zoom/virtual activities.

Respect and keep confidential all client/agency records and information and perform work of the highest quality, with dignify, courtesy, and professionalism.

Follow all rules, regulations, policies and procedures of the agency/business. Stay within the scope of assigned tasks/responsibilities. Use good judgment and avoid risky or inappropriate requests/situations.

Report problems, emergencies, safety hazards, or concerns to the site supervisor and to the instructor as soon as possible so they can be handled quickly.

Complete course service-learning assignments/projects as scheduled including weekly discussions and weekly time log reports (reflecting hours completed each day).

Course Information

Course Name

Course Number & Section

Is this a 8 or 16 week course?

Instructor Name

Semester & Year

Which type of service learning are you particpating in?

Number of Service Learning hours required for on-site (in the field)

Number of Professional Interview(s) required

with approval of your instructor

Service Learning Site Information

Name of Service Learning Site

or Enter Professional Interview Name

Name of Site Supervisor

Site Supervisors Phone Number

Site Supervisors E-mail

Physical Address

Please include City and State

Date Student Began Working

Can also enter date(s) professional interview will be conducted

Host Site Responsibilities

Provide orientation and training for the student volunteer including an introduction to the agency, the work it performs, and with whom the student will be working.

Explain agency rules, regulations, policies, and procedures to the student.

Provide the student supervision and training.

Clarify tasks and days/hours of participation with the student.

Answer questions and address concerns the student may have.

Discuss any problems/concerns about the student’s performance to the course instructor.

Complete an evaluation of the student’s performance.

Confirm that all service learning hours required have been met.

Student Acknowledgement

As a service learning student, I am a community volunteer. I understand that it is my responsibility to secure a service learning site. I will seek assistance from my instructor as needed.

I understand there are inherent dangers and risks found in any type of off-campus activities including, but not limited to, transportation delays or accidents, victimization by criminal activity, injury, and illness. As a student volunteer I will work with various agencies/organizations and populations served by those agencies/organizations. I have carefully considered these risks and dangers before deciding to continue with my service learning agency/organization. I further understand that service learning agencies and organizations are fully independent of San Juan College. San Juan College assumes no responsibility or liability for personal or property injuries or damages caused by me resulting from my participating in the activities of agencies/organizations. Nor is San Juan College responsible for losses or expenses due to weather, strikes, hostilities, wars, natural disasters, terrorism or other such causes.

I certify that I do not have any health-related reasons or problems that preclude or restrict my participation in service learning. I hereby consent to first aid, emergency medical care, and, if necessary, admission to a medical facility for care or treatment for injuries I may sustain while participating in any activity associated with the service learning program.

I release and hold harmless San Juan College, its employees and representatives from any and all liability, claims, demands and causes or actions, with respect to any and all matters relating to or arising out of my participation in the service learning program. This release covers all claims I might have and any and all third-party claims relating to my acts or failure to act.

I acknowledge that prior to signing this form, I have read it and understand its terms and conditions and voluntarily sign it. I warrant that I am at least eighteen (18) years of age as of the date I signed this document.

If under 18 please contact the Center for Student Careers & Employment with the contact information below for a parent release form.

Confirmation of Registration

The Center for Student Careers & Employment will e-mail the student, site supervisor and instructor confirmation of the registration.

Questions

If you have questions please contact:

Center for Student Careers & Employment
505-566-3423
careercenter@sanjuancollege.edu
Room 1717 West Classroom Complex