Note: This form should be completed by the service-learner and their site supervisor, prior to the start of service. Return form to faculty within one week of beginning service-learning project.

Student Name:
Local Address:
Local Phone:
Cell phone:
Student email:
Course Title:
Course Number:
Faculty Member/Instructor:

Name of Placement Site:
Supervisor Name:
Address:
Phone:

Days and times students will be in the agency:
Start Date_____________
End Date_________________

Learning Goals of Course (To be provided by faculty member)

1.

2.

3.

Purpose of the Service-Learning Contract:

1. To assist students and agency in understanding the learning goals of the course.
2. To clarify the activities in which the student will be involved in the agency in relation to the learning goals.
3. To insure that both the student and the agency are aware of the responsibilities as partners in this service-learning project.

Student’s Responsibilities:

1. To show up, on time and every week at the agreed upon time.
2. Call and inform the agency ahead of scheduled time if you are unable to work because of an emergency. Plan ahead so papers and exams do not interfere.
3. Define with the community partner an appropriate set of responsibilities for your service-learning experience.
4. Be patient: be productive. Make the best use of your time at the agency.
5. Complete the number of hours required by the class and/or agency.

______________________________________________
Student Signature and Date

Agency’s Responsibilities

1. To help the service-learner develop a weekly schedule.
2. Provide information to the student about the agency and its services to the community.
3. Ensure a system is implemented to track service-learner hours each week (Forms available from the Service-Learning Coordinator, Polly Chandler)
4. Monitor the performance of the service-learner and provide feedback if comfortable.
5. Contact the Faculty member or the Service-Learning Office immediately if efforts to resolve problems with the service-learner are not successful.
6. Complete the evaluation form (provided by Service-Learning Coordinator) and return to the student that the completion of their service.

Agency Supervisor Signature Date

___________________________ _____________ ____________________
Agency Supervisor’s Name Phone email

Agreement:

I agree to honor the minimum commitment required for the service-learning option in my class, as well as any of the additional training and/or time requirements of the service learning site as detailed by the course syllabus and the agency. I also agree to contact the instructor and the site supervisor should I have any concerns about my service-learning project.

Student Signature_____________________________________ Date __________

I have reviewed this contract and found the course objectives and the service activities appropriately matched. I have explained to my students and to the agency what I expect from the students as demonstrated evidence of their learning based on the service experience.

Faculty Signature _________________________________________ Date__________

I agree to provide adequate training and supervision for the service-learning student, to plan for activities that meet the stated learning goals for the student’s course, and to complete the necessary service-learning forms (contract and evaluation) by due dates. I also agree to contact the instructor should I have any concerns about the service-learning project or student.

Agency Signature _________________________________________ Date__________

Any Questions about this Form or Service-Learning contact:
Polly Chandler, Service-Learning Coordinator
Phone 358-2785 or email pchandler@keene.edu