Service-Learning Student Information Form

Semester:

Fall
Spring

Year:

Faculty Sponsor:

Name

Course Name:

Course Number:

Have you participated in a service-learning project before?

Yes No

If Yes, which project and when?

Contact Information:

Name
Address
City
State/Province
Zip/Postal Code
Home Phone
E-mail
Student ID #

What is the best way to reach you?

Phone
E-Mail
Snail Mail
Other 

Best times to call?

Emergency Contact Information:

Name
Address
City
State
Zip
Work Phone
Home Phone
E-Mail
Relationship
E-mail

Demographic Information:

Age
Sex	Male Female
Ethnic Background (Optional)