Student Assignment Form
The Center For Service Learning
7201 Rossville Boulevard
Baltimore, Maryland 21237
Social Science and Human Development Building
L Building--Room 313A
Phone: 443-840-1409
E-mail: tgordon@ccbcmd.edu
Name (Please Print): ___________________________________
Instructor: _________________________________ Course Title: _______________________
Number of Service Hours to Complete: ________
Assigned Service Site: ______________________________________________
Site Supervisor: __________________ Service Site Telephone: _____________
Site Address: _____________________________________________________
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Service Dates: ______________________________ Times: __________________________
_______________________________Times: __________________________
_______________________________Times: __________________________
_______________________________Times: __________________________
_______________________________Times: __________________________
Additional Comments or special instructions: _______________________________________
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Service Learning Assistant Coordinator: _____________________________ Date Assigned: _____________
Please Note: Students participating in service learning activities are required to use this form as an official means of reference regarding their assigned agency/organization site, dates and times of their specific terms of service. In the event of questions contact the Center for Service Learning at CCBC Essex,443-840-1409, Division of Social Science and Human Development, Office: Room 313A. Thank you for your cooperation.
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