Service Learning
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Service Learning Application for Enrollment
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College____________________________ Instructor’s name ____________________________________ Course ____________________________ Section____________ Meeting Time _____________________ Name (last) ____________________________________ (first) ____________________________________ Address _______________________________________________________ Apt. _____________________ City _____________________________ State _______________ Zip Code __________________________ Phone# (home) ___________________________________ (work) _________________________________ Email address ____________________________________________________________________________ Date of Birth*____________________________ Sex: M / FSocial Security Number (student number) ___________________________________________________ Agency Selection:_________________________________________________________________________ Agency Number (1-61) as listed in newspaper: _______ Agency Name____________________________________________________________________________
Agency name:_______________________________________________________________ Contact Person:_________________________________________________________________________ Phone Number:__________________________________________________________________________ IMPORTANT
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