Bautista/Revised 9/10

Contact Form (completed by agency/organization where student will perform his/her Service Learning and turned in by student or agency contact person on before  December 3rd (Fall Semester)

                                                    SERVICE LEARNING

                                  Learning to serve and service while learning

Name of Service Learning Student: _______________________________________

Agency/Organization Name and mailing address:    ________________________________________________________________________________________________________________________________________________

Contact Person: ________________________       Phone:  ________________________

Title of Contact Person: ___________________________________________________

 Please complete the following brief data sheet and mail (Roschelle L. Bautista, Assistant Professor of Spanish, Humanities Department, 650 College Drive, Dalton, GA 30720) , fax (706-272-2610) or send by way of the student in a sealed envelope. It is important that this sheet be turned in by a responsible agency representative on or before the last day of classes. The student will not earn his/her service learning credit this semester if this paper is not turned in by the last day of the class in which the student is enrolled. If you have any questions, comments or concerns, please feel free to contact me at 706-272-4568.

  1. What dates did the student begin and end the Service Learning Project? (Example: 10/1/10-11/26/10) _______________________________

     2.    How many hours of service learning would you estimate the student completed     this semester? Circle one range.          

            7-9 hours               10-12 hours               13-15 hours              16-18 hours

     3.    How many different days did the student participate in the Service Learning?          

            5-6                   7-8             9-10             11-12       13-14         15-16

4.        Spanish language & culture skills are an asset for this agency. 

       (Circle yes or   no)   Yes        No        Sometimes       

5.        This student was dependable and responsible. 

        Yes        No          Most of the time        Some of the time


6.        This student met our expectations.    

            Yes        No          Most of the time        Some of the time


    7.    I would be willing to serve as an agency contact person for another DSC student    volunteer in the future.

      Yes      No           If Yes, phone # or email where you can be reached by student volunteer:

      Phone:             ______________________________

      Email:              ______________________________



Bautista/Revised 9/10


Learning to serve and service while learning

STUDENT FORM (to be completed by student and turned in no later than October 8, 2010.


Full Name:  ____________________________________________________________________

Course, Section number and class meeting time:_____________________________________    

Term: _________________________________

Name of Agency or Organization:  ________________________________________________    

Name of Immediate Supervisor or Contact Person & Phone Number (with area code):


Mailing Address of Agency w/ zip code





Service Start date: _____________                   Service End date: _____________


Description of Service Learning Project:  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your goals by participating in this project: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

By signing below I am stating that I will dedicate a minimum of fifteen hours over a period of 10-14 weeks (full session), 5-8 weeks (half session) or 4 weeks (summer mini-session) to this service learning project. I will document the times & dates spent on the project and turn it in to my Spanish instructor when requested at mid-semester.  I will also be asked to write a 250 word reflection essay on my service learning experience. I acknowledge that if my contact person does not return the Service Learning Project Completion form by the deadline, I will NOT earn the maximum points allowed for my course. Furthermore, I understand that there is no partial credit if I withdraw from the Service Learning program. If I should decide not to continue the Service Learning Project, I may earn extra credit through the normal process with a cap of 25 points total. If I should withdraw from Spanish class, I may continue my community involvement without expecting the benefit of receiving classroom points during another semester in which I might be enrolled in Spanish at Dalton State. If I should decide not to continue the community involvement but want to continue being enrolled in Spanish class, this, of course, is allowable. However, I will notify the appropriate persons in the service agency of my desire to discontinue my service so that they may plan accordingly. I understand that points earned for Service Learning in Sra. Bautista’s class do not transfer to any other course or class taught by Sra. Bautista or any other instructor.

Finally, I acknowledge that I must also log my hours volunteered and complete any necessary paperwork online at the Student Services website

___________________________________                          ______________________

Signature                                                                                  Date

Classroom benefits of participating in Service Learning

ü  One exam exemption (maximum 75 points)

ü  One homework credit (maximum 20 points) or quiz credit (maximum 25 points)

ü  Two additional class absences more than what is stated on syllabus