Mcps Form 560-50 - Request For Student Service Learning (Ssl) Preapproval - Montgomery County Public Schools
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1
2Office of Curriculum and Instructional Programs
REQUEST FOR STUDENT SERVICE
MONTGOMERY COUNTY PUBLIC SCHOOLS
LEARNING (SSL) PREAPPROVAL
Rockville, Maryland 20850
STUDENT INSTRUCTIONS: Complete this form legibly in ink and have it approved by the student service learning (ssL) coordina-
tor prior to earning ssL hours with an organization or opportunity that is not tagged as MCPs ssL Approved at the website www.
. Maintain copies of all forms for your records.
STUDENT INFORMATION—To be completed by the student allowing 2 weeks for review by the school SSL coordinator.
student’s name
iD no.
Last
First
MI
Parent/Guardian
Phone: Home
-
-
Work
-
-
school
Grade
First Period teacher
E-mail
identify what you will do
Proposed dates of service: From
/
/
t o
/
/
. (maximum 1 school year)
/
/
Signature, Student
Date
PARENT/GUARDIAN APPROVAL: My signature below verifies that:
• i approve and accept full responsibility for my child’s participation in this opportunity with this organization.
• i know this request must be approved by the ssL coordinator prior to my child beginning the activity.
• i understand that by participating in this activity my child will not receive direct supervision from MCPs staff or from anyone
who has participated in the MCPs ssL training available to nonprofit, tax-exempt organizations.
• i understand that there are approved ssL organizations and opportunities available to my child where supervision is
provided by MCPs staff or supervisors from nonprofit, tax-exempt organizations that have participated in ssL training and
agree to adhere to MCPs guidelines.
/
/
Parent/Guardian Name (PRINT)
Signature
Date
NONPROFIT, TAX-EXEMPT ORGANIZATION INFORMATION AND AGREEMENT—To be completed by the supervisor
organization name_____________________________________Federal Employer identification # __ __ - __ __ __ __ __ __ __
Address
Street
City
State
ZIP Code
Phone
-
-
Fax
-
-
secular activities to be performed by student include
My signature below verifies that
• i am 18 years old or older.
• i agree to the ssL guidelines listed on the back of this form.
• i agree to supervise the student in the above activities in a public place.
/
/
Name (Print)
Title
Signature, Supervisor
Date
APPLICATION REVIEw BY SSL COORDINATOR
□ Approved □ Disapproved
□ this does not meet ssL guidelines.
□ other (explain)
/
/
Signature, Student Service Learning Coordinator
Date
Student Follow Up: submit completed MCPs Form 560-51: Student Service Learning Activity Verification to the school ssL coordinator.
• by the last Friday in september for summer service
• by the Friday before first semester exams begin to document service during the First semester
• by the Friday before second semester exams begin to document service during second semester
➞
MCPS Form 560-50, Rev. 3/11
Distribution: Copy 1/student service-Learning Coordinator; Copy 2/student
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