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Community Service Learning Plan
Student ID#:
Last Name: First Name:
Date of Birth:

Approximate # of Hours per week:
Start Date: End Date:

Learning Objectives: What do you hope to learn from this service experience—about the agency, about the
challenges and assets of the population with whom you will be working, about yourself, and about your
community—and how does this connect to your course work?


Service Objectives: Identify and describe the nature of the service activities in which you will be engaged.
The service objectives should be designed to help you work toward your learning objectives.


Service Outcomes & Indicators: Provide at least one realistic, measurable community outcome that should
result from your service, and a way in which that outcome can be observed. Example: Outcome- Tutoring will
result in the child’s academic improvement. Indicator- Child’s reading level will raise by at least one grade level.


As part of your service, are you required to:
drive a vehicle? Yes No
travel? Yes No

Risks that may be involved with a service learning experience include:
1) Personal safety in an urban environment
2) Protection of personal property in an urban environment
3) Potential for injury if involved in recreation or sports-related activities
Please list any other risks you can identify at your service placement below:


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