Editing previous response:

Please fix the highlighted areas below before submitting.

Service Learning Other

Fieldwork Request Form

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

First Name

Answer Required

Last Name

Answer Required

Home Phone

Number Required

Daytime Phone

Number Required

Cell Phone

Number Required

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Total Hours Needed

Answer Required

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

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

Class for which you are doing your observation/fieldwork:

Answer Required

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

Answer Required

Instructor's Name

Answer Required

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

Answer Required

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

Answer Required

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

Answer Required

With how many children do you need to work?

Answer Required

Other considerations

Answer Required