$ervice Learnin$ PreapproveX (1O Hours)

your contact hours

complete this form and submit to your csN instructor before proceeding with
Your Full Name (Print):

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CSN Professor (Print):

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Name of AgencY/Contact Person

Agency Address:
Ageney Phone:

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Contact Person's email:

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DTRECTIONS: Complete the fottowing3 sections

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so that your instruetor and impaeted ageney is aware

of your service learning requirement plan'

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NEED/pURpOSE: - Why is this seryice needed? How witl

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hetp the community?

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what do t personally hope to gain from

ouTcoMEs : - what positive impact wiil thisservice have on the community?
person to verify my participation?
the experience? what evidence do t need to coileet frcm thg ageneylaontact

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S/GNAIUPES:

will begin on
have reviewed this service proposal and approve to proceed' The service

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Agency/Contact Person's APProval: