Service-Learning Placement Confirmation Agreement

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Service-Learning Placement Confirmation Agreement- REQUIRED
To be completed by Agency/Organization/Individual that will act as the supervisor of the RSC Student participating in a Service-Learning Project
Name of Student ID # _______________________
Name of RSC Instructor
Name of Agency/Organization/Individual
Agency Contact Person/Supervisor
Address
City Zip
Phone FAX
E-mail
The agency agrees to provide the student with on site supervision and a critique of the student’s work at the end of the service-learning experience.
I agree to and will uphold, the terms of this placement
Supervisor’s Signature
Date
Students should return forms to Cindy Brown, Social Sciences, SS 136-C, Rose State College, 6420 S.E. 15th St., Midwest City, OK 73110, FAX 736-0324, email cabrown@rose.edu