Service-Learning Plan Agreement
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Service-Learning Plan Agreement
Section I: Student Data
Student’s Name:
Email: Telephone Number:
Section II: Service Site
Service Site Name: _____________
Contact/Supervisor Name:
Service Site Address: _______
Email: Telephone Number:
Section III: Course Data
Year/Semester ________ Course Title (eg CRIM 120S):__________________________
Faculty Name: _________________
Learning Activity (list your primary activities/responsibilities at the Learning Site):
Learning Objectives – Through this course students will:
Planned Number of Service Hours: _______Start Date:_______________ End Date: ___________________
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Student Guidelines and Provisions
1. I understand and acknowledge that there are potential risks associated with this service-learning experience, some of which may arise from (a) my assigned tasks and responsibilities, (b) the Service Site location, (c) the physical characteristics of the Service Site, (d) the amount and type of criminal activity or hazardous materials at or near the location of the Service Site, (e) any travel associated with the service, (f) the time of day when I may be present at the Service Site, (g) the criminal, mental and social backgrounds of the individuals I will be working with or serving, and (h) the amount of supervision I will receive. I further understand and acknowledge that my safety and well-being are primarily dependent upon my acting responsibly to protect myself from personal injury, bodily injury or property damage.
2. I acknowledge all related risks, both known or unknown to me, of my participation in this activity, including any travel to, from and during the activity. I understand that I may stop participating at any time if I believe the risks become too great.
3. While participating in this service-learning activity, I will (a) exhibit professional, ethical and appropriate behavior; (b) abide by the Service Site’s rules and standards of conduct, including wearing any required personal protective equipment; (c) participate in all required training; (d) complete all assigned tasks and responsibilities in a timely and efficient manner; (e) request assistance if I am unsure how to respond to a difficult or uncomfortable situation; (f) be punctual and notify the Service Site if I believe I will be late or absent; and (g) respect the privacy of the Service Site’s clients.
4. While participating in this service-learning activity, I will not (a) conduct my service activities under the influence of drugs or alcohol; (b) give or loan money or other personal belongings to a client; (c) make promises to a client I cannot keep; (d) give a client or representative a ride in my personal vehicle; (e) engage in behavior that might be perceived as harassment of a client or Service Site representative; (f) engage in behavior that might be perceived as discriminating against an individual on the basis of their age, race, gender, sexual orientation, physical and/or developmental or intellectual capacity or ethnicity; (g) engage in any type of business with clients during the term of my placement; (h) disclose without permission the Service Site’s proprietary information, records or confidential information concerning its clients; or (i) enter into personal relationships with a client or Service Site representative during the term of my placement. I understand that the Service Site may dismiss me if I engage in any of these behaviors.
5. While participating in this learning activity, I will expect the following from the Learning Site. They will (a) exhibit professional, ethical, and appropriate behavior; (b) not engage in behavior toward me that might be perceived as harassment or discriminatory due to my age, race, gender, sexual orientation, mental capacity, or ethnicity; (c) not pursue, coerce, or otherwise suggest that a personal relationship is expected or desired.
6. I agree to contact the University’s Administrator of Environmental Health & Safety, Risk Management at 559.278-6910 if I believe I have been discriminated against, harassed or injured while engaged in this service activity. Please call Campus Police after hours at 559.278-8400.
7. I understand and acknowledge that neither the University nor the Service Site assumes any financial responsibility in the event I am injured or become ill as a result of my participating in this learning activity. I understand that I am personally responsible for paying any costs I may incur for the treatment of any such injury or illness. I acknowledge that the University recommends that I carry health insurance.
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General Provisions:
1. The Service Site agrees to provide an orientation that includes a site tour; an introduction to staff; a description of the characteristics of and risks associated with the Service Site’s operations, services and/or clients; a discussion concerning safety policies and emergency procedures; and information detailing where students check-in and how they log their time. They will also provide applicable training and safety equipment that may be necessary.
2. The Service Site should notify the University as soon as is reasonably possible of any injury or illness to a student participating in a learning activity by calling 559.278-6910 or 559.278-8400.
3. The Service Site and the University will meet upon request or as necessary to resolve any potential conflicts and to facilitate a mutually beneficial experience for all involved. If it is determined that the service-learning placement fails to be in the best interest of the scholar, service site, and/or California State University, Fresno, either party (the university or the service site) may terminate this particular service-learning placement upon giving written notice as soon as reasonably possible to the other party.
4. The Service Site may dismiss a student if the student violates its standards, mission or goals. The Service Site will notify the University as soon as reasonably possible of the student’s dismissal.
I have read, understand and agree to comply with these guidelines.
Student Signature: _____________________________________________ Date:
Student Name (please print):___________________________________
Service Site Supervisor Signature: _______________________________ Date:________
Service Site Supervisor Name (please print):______________________
Faculty Signature: ____________________________________________ Date: ________ ______
Faculty Name (please print):
If student is under the age of 18 please complete
Parent/Guardian Name: Date: _________
Parent/Guardian Signature:
Updated 7/20/23
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