Agency/Organization Information

Name of Agency/Organization_______________________________________________

Address________________________________city/state/zip_______________________

Name of contact person ___________________________Title_____________________

Phone # ____________________Fax # ________________ email __________________

1. Describe the services your organization provides:

2. Describe the type(s) of duties that students can perform for you:

3. How many service learning hours are you requesting?

_________/week __________/month __________/semester

4. Which times are best for students to participate?

____mornings ____afternoons ____evenings ____weekends

Indicate specific times if necessary:

5. How many students can you effectively work with each semester? _______

6. Do you provide an orientation for new participants? ______YES ______NO

7. Do you provide training for participants? ______YES ______NO

8. Do you provide on-site supervision? ______YES ______NO

9. Are you willing to write an end-of-semester assessment if requested?

______YES ______NO