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Service Learning

Fieldwork Request Form

Please complete the form below. Required fields marked with an asterisk *

First Name

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Last Name

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Home Phone

Number Required

Daytime Phone

Number Required

Cell Phone

Number Required

Answer required for "Email"

Street Address

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City

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Zip/Postal

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Total Hours Needed

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Do you need to complete fieldwork/service learning in a particular content area or activity (e.g. Language Arts, Math, PE, Music, etc)? Please describe.

Answer required for "Do you need to complete fieldwork/service learning in a particular content area or activity (e.g. Language Arts, Math, PE, Music, etc)? Please describe."

If requesting service learning for SPED 200 (Disability Studies), what skills or special interests do you have that may be an asset in your service learning assignment? (describe)

Answer required for "If requesting service learning for SPED 200 (Disability Studies), what skills or special interests do you have that may be an asset in your service learning assignment? (describe)"

Class for which you are doing your observation/fieldwork:

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Please describe the class assignment for which you are completing this fieldwork or service learning:

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Instructor's Name

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Number of visits requested, and number of hours per visit:

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Specific days and times available (note: observation requests may take up to a week to complete. Please note school hours listed above):

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What type of work do you need to do with the students?

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With how many children do you need to work?

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Other considerations:

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