Kirkwood Community College
STUDENT/ORGANIZATION INFORMATION & PLACEMENT CONFIRMATION FORM
*Directions: Student is to complete this form with contact person & return to instructor by {_______}*
Semester {
}
Class {
Student Name
Phone (
Student Address
State
}
)
Best time to contact:
Zip
Email address:
Organization assigned to:
Address
Phone (
State
)
Extension:
Zip
Coordinator/Contact Person
Email address:
Classroom teacher(s)
Phone (
)
Extension:
Schedule days and hours of service:
Program type/grade level:
Duties:
Goals:
I agree that the statements above are adequate description of my service assignment and that I will do my best to live
up to these obligations. I also agree to notify my agency contact person in advance if I will be absent or late for any
reason.
Student signature:_________________________________________________Date:__________________
I agree that the above organization accepts this student as a service-learning student, and that we will provide
support, resources, and supervision to assist the student in meeting their service-learning goals.
Contact Person for organization:______________________________________Date:__________________
Jean McMenimen ~ Service-Learning Coordinator
Kirkwood Community College
6301 Kirkwood Blvd. SW~1017 Cedar Hall
Cedar Rapids, IA 52406
319-398-5899 Ext. 5019 Toll Free~800-332-2055 Ext. 5019
mailto:jmcmeni@kirkwood.cc.ia.us
Instructions
White Copy~ Service Learning
Yellow copy~ Class Instructor
Pink copy~ Organization
Golden copy~ Student