Service Learning Agreement Form - Chicago Public Schools printable pdf download

SERVICE LEARNING AGREEMENT

Chicago Public Schools

Name: _________________________________ Home Phone: ____________________________

School: _________________________________________________

Division # ______________

Home Address: _______________________________________________ Zip Code: _________

Site/Project Name: _________________________________________________________________

Site Address: __________________________________________________ Zip Code: __________

Site Contact Name: ____________________________________ Title: ______________________

Site Phone: _________________________________ Project Date(s): _______________________

Basic responsibilities: _______________________________________________________________

I, the above student, have elected to provide service at the above site. I agree to abide by the

regulations/ policies of this site and the Chicago Public Schools and to provide to the best of my ability

the tasks specified in this agreement. I agree to call the site in advance if I am detained for any reason.

Failure to do so may result in termination of this agreement.

_____________________________________________

______________________________

Student signature

Date

This site agrees to accept the services of the student as specified and to provide meaningful tasks for

this student. In exchange for services rendered, this agency will train, supervise and evaluate the

student. We will not expect the student to participate in activities that would be considered unsafe for

the age and experience of the student. This is to acknowledge that we ____ do ____do not (check one)

provide general liability insurance protecting the student when he/she is involved in this service project.

_____________________________________________

______________________________

Site contact signature

Date

I, the parent/legal guardian of the above student, approve his/her participation at this site and agree

to lend support and encouragement to my child in the service he/she will render to the site we have

chosen. I accept responsibility for my child’s transportation to and from the site.

_____________________________________________

______________________________

Parent/guardian signature

Date

MEDICAL RELEASE INFORMATION

If the parent/guardian is unavailable, please notify the emergency contact person below:

Name: ___________________________________________________

Phone: ____________________________

The student has my permission to be transported and treated by any doctor assigned by the service site

in an emergency or accident.

______________________________________________________

____________________________________

Parent/guardian signature

Date

Please return this form to your Service Learning Coach.

Service Learning Agreement Form - Chicago Public Schools

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