Mississippi College Community Service Center
BCR Student Center – Shari Barnes (Director) 925-3413/259-5573
Name (please print) ____________________________________________________________
Current Address _______________________________________________________________
Email _____________________________ Current Telephone__________________________
Classification:  Freshmen  Sophomore  Junior  Senior  Faculty  Other
If involved for course related service, please complete the following:
MC Instructor’s Name__________________________________________________
MC Course _____________________ Class Time & Date ____________________
If involved for any social tribe or other clubs, please complete the following:
Club Name __________________________________________________________
Service Chair (or president if no chair) ____________________________________
Above Contact’s Telephone ____________________________________________
Agency(s) Name of interest to you: ___________________________________
___________________________________
To the student:
It is very important that you meet with the above agency at the specified time, observing punctuality. If you find that you are unable to meet with the agency and need to reschedule the appointment for another time/date, please contact the agency or the Service Center office.
Also, if you are not happy with your current service-learning experience, it is your responsibility to resolve the issue by speaking with the agency supervisor about your concerns, or by contacting the Mississippi College Community Service Center for assistance in resolution or referral to another agency. Remember, service-learning is a learning experience; make the most of your experience, even if it is not what you expected.
Student Signature _________________________ Date ___________________________
Service Center Referring Representative Signature ______________________________