CSUMB Service Learning Volunteer Identification Form

CALIFORNIA STATE UNIVERSITY, MONTEREY BAY
Service Learning Volunteer Identification Form
Semester: _____________________________________
Department: _______________________________________
Name: ________________________ _________________________ __________ Date of Birth: ____ /_____ /_____
Last
First
MI
Month
Day
Year
Address: ______________ ____________________________________________________________________
Phone Number: (______________ _____) ___________ - _____________________
Emergency Contact: ______________________________________ (_________) __________ - _________________
Print
A rea Code
Phone Number
Site Name: ________________________________________
Site Address: ____________________________________________________________________________________
Site Supervisor/Teacher’s Name: ___________________________________ (_________) __________ - ____________
Print
Area Code
Phone Number
1 Assignment and Summary of Duties: A Learning Agreement has been submitted and is on file in the department listed
above:
Yes
No
2 Will your service activities require you to drive to any other locations than your primary site in order to accomplish your
service and/or learning objectives?
Yes
No
3 Will your service activities require you to travel to any other locations than your primary site in order to accomplish your
service and/or learning objectives?
Yes
No
If YES to 2 and/or 3, please indicate Social Security number: _______________________________________________
Note: CSUMB Students may not drive company vehicles, or use personal vehicles to provide services for their community-based
organization.
Are you receiving academic credit for volunteering?
Are you a University student, staff or faculty member?
Yes
Yes
No
No
I, (student name) hereby certify that all statements on this form are true to the best of my knowledge. Any falsification of the the
info may be considered grounds for termination of my volunteer status. I desire to volunteer my services at my service learning
site, performing my duties as stated in my CSUMB Learning Agreement and that the services rendered by me will be at the
direction of my Site Supervisor. I will not be compensated for these services. Further I understand that I serve at the pleasure
of my Site Supervisor.
Do you agree with this statement?
Yes
Date: ______________________
_______________________________________________________________________________________________
Approval of Campus Personnel
SLI 1/05
S:\CSU Site\CSL\programs\CSUMB_Volunteer_Form.doc
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Date