re* T

m .d T
.m,s .r{ }*LJ
r\ r-r*:
ren\
"m * ffiffi
xl.t'Lir"b.l
i*"J\-lm
**J\}edr&
-t&$&em

mryuqrt
"Q
e*;ffi.d1d j-"\*ddJ

&l

"*

EDU 2O1, EDU

?,OP,,

EDU

?*.O.5

Farticipation Leg: C*mplete S*t*,rice Learning fhoi*es i* equai i G ft+ur* or rncr*.

Be sure io atiach specific additional docurnents required for each iype of service listed beiow.

Your Full Name (print)r

Community Servicer

Componeni in which the studeni works in a volunteer

capacity at any organization that will allow volunteers, that
serves the betterment oi school age children in the
csmn]unity, and one in which the student can obtair, a

verified letter of participation or certificate frcm the

organization's leadership documenting participation and
hours of credit.

Agency/Type of Service

t-lnc\ison

Srnr

iln

Date(s)

n.

Date(s)

rA

Date(s)
r Private School Service:
The student musl obtain written permission from the
school's administration prior to visitation, and must have an

+ hr 2 ryrin

Total Hours:

officer of the school provide signed veriricetion upon school

letterhad ot the

iFe

at, and duration ot ihe sryie

. Organized Field Trip:

Your CSN instructor may be able to organize an education
based field trip in which all members of the class meet at

Supervisor Name (print):

Supervisor Signature:
Supervisor Phone:
Supervisor e-mail:

another location, instead of attending class at the regular

scheduled at time. Students must fill out CSN's Field Trip
Waiver and provide it to the instructor before traveling to an offeampus event. Credit hours and verification for this experience
will be determined by your instructor.

. Additional participation at school assigned by

CCSD during Field Observation:
the CSN studenl and astigned CCSD cooperaiing leacher
agree, a student can simply choose to remain at the assigned
school and classroom beyond the mandatory 1 0 hours of Field

Observation, and continue accumulating up to 10 additional

Agency/rypeof

service:

312tlr{

Date(s)
Date(s)

Other Seruice

and present a different service

oriented educational experience to their instructor. The

The student can design

\orrrs

Date(s)

Total Hours:

hours at the site. The student and cooperating teacher are

encouraged to increase the level of active participation by the
CSN student beyond a simple passive obsenr'ation,

&;r.; ( tetn\Enta"ry

Supervisor Name (print):

Supervisor Signature:
Supervisor Phone:
Supervisor e-mail:

proposal must be in writing and agreed upon by the CSN

student and CSN instructor prior to accumulation of hours.

Agency/Iype of Service

Date(s)
Date(s)
Date{s}

Total Hours:
Supervisor ltame ffint|:
Supervisor Signature:

Supervisor Phone:

y-. 62