* = Required Field
Student's First Name:* Last Name:*
Student's ID Number:*    
Street Address:*
City:* Zip Code:*
E-Mail * Phone Number*
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: * .


List topics of community interest in which you would like to participate: *
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.
Student Data:
Date of Birth
(Ex. 01/01/83)*
 Sex  Female        Male      Decline to State    
Ethnic Identification:
African- American American Indian/Alaskan Native
White/Caucasian Non-Latino/Hispanic Filipino
Asian Latino/Hispanic Pacific Islander
Decline to State Other Non-White
Units enrolled in this semester:
Units completed to date:    
Overall g.p.a.    
Please check one: *
I plan to transfer/graduate at the end of this semester
I plan on continuing my education at College of the Canyons next semester
Expected transfer/graduation date: (Ex. 01/01/83)
Academic Major:      Career Goals:
Languages you speak other than English:
Do you have any previous service or volunteer experience? * Yes     No
If yes, how many different agencies?
If yes, (approximately) how many total hours?
List agencies you have volunteered for in the past:
List skills you acquired from volunteering:

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.