Chaminade-Madonna College Preparatory

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Service Learning Agreement Form

Chaminade-Madonna College Preparatory views service as integral to personal growth and faith development. Therefore we encourage our students to embrace opportunities to give of themselves to others through service. As a faith community we believe that the scriptures prescribe an ethical imperative for living the gospel in today's world. As our school mission statement reminds us, the individuals of this community:

Share their faith, achieve excellence, and become caring participants and leaders in the service of community, church, and those in need.

This Service-Learning Agreement is designed to clarify expectations, communicate learning objectives, promote safety, and foster communication.

This form must be completed after participating in a service activity. You can fill out the form on this page, print it out, sign it yourself, and have your supervisor sign it before turning it in. Alternatively, you can print out the form as a PDF here (96 KB).

Student Service Form

Student Name

Student ID Number

Student Theology Teacher

Student Phone

Student E-Mail Address

Name of Agency

Supervisor Name

Supervisor Phone

Student please initial each of the following statements.
I agree that I have:

______ Performed my service duties to the best of my ability.

______ Respected the policies, regulations and confidentiality standards of the agency.

______ Displayed a professional behavior while at my agency which includes promptness, appropriate dress and language, and at least 24 hours advance notice if I was absent.

______ Been an active learner using supervisor feedback and asking questions to facilitate learning.

______ Completed hours of service with the above agency.

Agency/Supvervisor Form

Supervisor please initial each of the following statements.
I agree that the student named here has been honest with the above information regarding their service under my supervision and that I have provided the following:

______ Completed the forms and evaluations provided by the C-M Service-Learning Program.

______ Provided any necessary training and information for the service-learner including information on the overall operation of the agency and its role in addressing social issues and needs.

______ Provided supervision that holds the student accountable, and also encouraged questions and suggestions from the student.

______ Evaluated student performance at the end of the duration of their service.

______ Contacted the Service-Learning Coordinator should a problem have arisen with the student’s performance.

Date(s) of service activity From To (mm/dd/yy)

Description of the service activities the student performed

Student Signature / Date ___________________________________

Supvervisor Signature / Date ___________________________________

Supervisor please initial each of the following statements. I agree that the student named here has been honest with the above information regarding their service under my supervision and that I have provided the following:
______	Completed the forms and evaluations provided by the C-M Service-Learning Program.
______	Provided any necessary training and information for the service-learner including information on the overall operation of the agency and its role in addressing social issues and needs.
______	Provided supervision that holds the student accountable, and also encouraged questions and suggestions from the student.
______	Evaluated student performance at the end of the duration of their service.
______	Contacted the Service-Learning Coordinator should a problem have arisen with the student’s performance.

Date(s) of service activity	From To (mm/dd/yy)
Description of the service activities the student performed
Student Signature / Date	___________________________________
Supvervisor Signature / Date	___________________________________