* = 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 .

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

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.