* = 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 Section Number:*
Course Name and Number :*
                                      (example: Bio 106, Eng 101, Hist 112, Polisci 150)
Number of hours required to complete this project is .


Disclaimer for Service-Learning Students:

Please note that all students are held responsible to read and understand all the listed material in the Service-Learning handbook. It is the students’ responsibility to properly enroll in the Service-Learning Program.  If the student wishes to drop from the Service-Learning Program at any given time, it is the student’s responsibility to contact the Service-Learning Staff. Also, if you are participating in Service-Learning for multiple classes you are responsible to complete all the required components for each class unless otherwise arranged by the Service-learning office. If you have any questions or concerns throughout the process feel free to contact us at (661) 362-3231 or email us at

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.

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