STUDENT SERVICE LEARNING APPLICATION

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WALKERSVILLE HIGH SCHOOL

NAME___________________________________________________________

ADDRESS________________________________________________________

CITY/TOWN _________________________ STATE _________ ZIP ________

DOB____________ SS# ____-____-_______ HOME PHONE_______________

GPA ____________ ATTENDANCE (Days absent this year)__________________

Do you have your own transportation? Yes______ No______

Service Learning

Area of Interest _____________________________________________________

__________________________________________________________________

Peer tutor or agency preference _________________________________________

What is your service plans? ____________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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Student Signature

______________________________

Service Learning Coordinator

______ Approved ______________________________

______ Denied Supervising Teacher’s Signature