Student Forms

Several of the following forms are required for the Service Learning placement process. Please read the descriptions below. Then download the form needed by clicking on it and complete the necessary paperwork for your Service Learning experience.

Learning Agreement - Required

Learning Agreement

  • Must be completed before beginning service
  • Submitted to the faculty and kept for the semester
  • Submitted to the Service Learning Institute at the end of the semester

What is the Learning Agreement?

The Learning Agreement is the official document used to describe a students' responsibility at their service learning site.

The student, course instructor and site supervisor must sign the Learning Agreement. It is kept on file in the SLI for 3 years.

Students can, also, access this form via MySLP after completing the online placement process.

The Learning Agreement PDF form below is editable on your computer so you can fill in most of the segments before printing.

Note: You MUST download it to your computer first before you fill it in otherwise it will not save your information.

Short-Term Placement Agreement

Short-Term Placement Agreement

  • Used for one-time placements (one student only) with a new organization
  • Submitted immediately to the Service Learning Institute for tracking

What is a Short Term Agreement?

This form is for students wishing to serve at a site that has yet to be established as a University Community Partner. It is an agreement that is only valid for one semester. Before completing the Short-Term Placement Agreement, students must first obtain approval from their instructor and the organization with which they wish to complete the internship.

Activity & Time Log - Required

Activity/Time Log

  • Completed throughout the semester by the student
  • Signed by the supervisor at the end of the semester
  • Submitted to the faculty as part of the final grading process
  • Submitted to the Service Learning Institute at the end of the semester

What is an Activity Time Log?

The Activity & Time Log is provided to assist students in tracking the activities and number of hours served at your service learning site. Once completed and approved by your site supervisor, it provides verification of your service to the organization as well as a history of your contributions to the site. You are responsible for completing and returning this form to your service learning professor at the completion of your service, so please check with your professor for the due date.

Evaluation of Service Learning Process By Student

Each semester, all students enrolled in SL courses will be asked to complete an online survey of the Service Learning process. An individual link will be sent to each student (via email) with directions for the Evaluation. This evaluation gives students the opportunity to provide feedback on the effectiveness of their Service Learning experience and will assist in future program development.

Evauation of Student By Agency

This form is to be used at the discretion of the CSUMB faculty. Students, please check with your instructor to see if this form is required, as your service learning course professor may consider the remarks of this evaluation in determining your final grade in your service learning course.

Evaluation of Student by Agency

  • Completed by the supervisor at the end of the semester
  • Submitted to the faculty as part of the final grading process

Campus Health Center (CHC) Forms

Students, please complete the New Patient Intake Form below if you have never visited the Campus Health Center and bring it with you on your fist visit. Your answers on this health intake form will help your CSUMB Campus Health Center clinician understand your medical concerns and conditions better.

CHC - New Patient Intake Form

The CHC Notice of Privacy Practices form below describes how students' medical information about may be used and disclosed and how to gain access to this information.

CHC - Notice of Privacy Practices

The Notice of Privacy Practices Acknowledgement form below should be completed after reviewing the Notice of Privacy Practices.

CHC - Notice of Privacy Practices - Acknowledgement

The Tuberculosis PPD form below should be completed by students who wish to request a Tuberculosis test. Students must bring this completed form when visiting the Campus Health Center.

CHC - Tuberculosis PPD Form

Students Working With MPUSD (Monterey Peninsula School District)

Students interested in serving at Monterey Public Unified School District (MPUSD) schools located throughout Marina, Seaside and Monterey are required to attend an MPUSD Orientation. All orientations will be held at the Service Learning Institute, Bldg 44 (Pacific Hall). If you do not attend the MPUSD Orientation, you cannot serve with MPUSD.

SPRING 2018 MPUSD Orientation Dates

Week 2: Thurs, Feb. 7th - 3:00pm

Week 3: Wed, Feb 7th - 9:00am & Thurs, Feb 8th - 1:30pm

Week 4: Tues, Feb 13 - 9:00am & Fri, Feb 16 - 1:30pm

Week 5: Tues, Feb 20 @ 5:30pm

ORIENTATION REQUIREMENTS:

Please be on time! Late students will not be admitted. Required forms are listed and linked below:

a. Student must have a completed MPUSD Form.

MPUSD Form 2016 - 2017

b. Student must have their TB test results or TB Risk Assessment Questionnaire completed.

TB Testing Process

Note: The Campus Health Center (CHC) are facing a high volume of student TB test appointments. In order to accommodate the students in a timely manner, the CHS is asking students to arrive at their appointment with completed intake registration forms.

Students, please complete the following forms prior to their TB appointment:

Having the forms completed will help expedite the process allowing the CHC to provide more TB tests per day.

Campus Health Center - New Patient Intake Form

Campus Health Center - Patient Information Form

Service learning students doing their serving at a school under the MPUSD can now provide a negative TB test result OR a TB Risk Assessment Questionnaire completed by a licensed health care provider. All other school districts do require a negative TB test result. Call the Campus Health Center to make an appointment at (831) 582-3965.

TB Risk Assessment Questionnaire form

c. Students MUST know the MPUSD school where they want to do their service. Students will be asked to choose a school site at the orientation.

d. Students MUST bring an official governmental photo ID to the orientation session. CSUMB ID cards are not acceptable.

For more Information please contact Rene Casas at 831-582-4184 or rcasas@csumb.edu

TB Testing Information

Students, please check with your site supervisor to ensure the listed policies and procedures are current at the time of your placement.

TB Testing Process

Note: The Campus Health Center (CHC) are facing a high volume of student TB test appointments. In order to accommodate the students in a timely manner, the CHS is asking students to arrive at their appointment with completed intake registration forms.

Students, please complete the following forms prior to their TB appointment:

Having the forms completed will help expedite the process allowing the CHC to provide more TB tests per day.

Campus Health Center - New Patient Intake Form

Campus Health Center - Patient Information Form

Background Check/Fingerprinting

Students, please check with your site supervisor to find out what process is used for fingerprinting/ background checks and how to receive your forms as not all sites require background checks.

For those sites that do require background checks, they are generally completed via "Livescans", which is an electronic means of taking your fingerprints. It is connected to the Department of Justice and FBI databases.

In order to complete your Livescan, you must get a Livescan form from your potential site supervisor. The organization's mailing and billing information must be pre-printed on this form.

To complete this process:

  1. Call one of the below listed agencies to schedule an appointment.
  2. Be sure to take your Livescan form (from your Site Supervisor) with you.

Fingerprinting Locations

Fingerprinting services are available on campus (via CSUMB Police Department) by appointment only. Listed below are public and commercial organizations that provide fingerprinting. For those requiring appointments, be sure to call ahead.

Please Note: The Boys and Girls Clubs of Monterey County (BGCMC) use the "Volunteer Select" background check process in lieu of Livescans. There is no cost to students for this process but it takes 3 to 10 days for results. This process requires you to complete and submit a form to BGCMC.

CSUMB University Police Department

Parking Services Department (Valley Hall 82E)

Monday, Wednesday, Thursdays and Fridays: 8:30 am-4 pm

Tuesdays: 8:30 am-11 am and 1 pm-4 pm

For appointments call: (831) 582-3573

Costs vary: Roll fee (fingerprinting): $15 for CSUMB students, faculty or staff

Additional fees, depending on community partner agency requirements:

Dept of Justice (DOJ) clearance - $32

FBI clearance - $17

Child Index clearance - $15

Monterey County Sheriff's Dept.

1414 Natividad Road, Salinas, CA 93906

(831) 755-3726

By appointment only Monday-Friday: 8:30 am-3:45 pm

Cost: The total fee to process a live scan depends on the level of service required for each applicant. There are many variables which determine the cost of the live scan.

Monterey Police Dept. (Live Scan)

351 Madison St., Monterey

(831) 646-3830

By appointment only Wednesdays 9:30 - 11:30 & 1:15 - 2:30

Cost: $77

The UPS Store- Salinas

1522 Constitution, Salinas, CA 93906 (Next to Safeway)

(831) 449-4999

Monday-Friday: 9 am-5 pm and Saturday: 11 am-4 pm

Cost: $25-$125 Walk-in. The total fee to process a live scan depends on the level of service required for each applicant. There are many variables that determine the cost.

The UPS Store- Marina

266 Reservation Road, Marina, CA 93933 (in Save Mart Center)

(831) 384-9516

Monday-Friday: 8:30 am-6:30 pm and Saturday: 9 am-5 pm

Cost: $25-$125 Walk-in. The total fee to process a live scan depends on the level of service required for each applicant. There are many variables that determine the cost.

Identifying A Site (For Distance Learners)

For distance learners or students looking to choose a site location that is not a current community partner, this form should be considered while choosing an appropriate site.

Identify an Appropriate Distance Learning Site

Chinatown Forms

This PowerPoint is meant to be viewed by students serving in the Chinatown Community, to gain more information about the atmosphere and overall safety requirements.

Chinatown PowerPoint

This form should be reviewed by students working in the Chinatown Neighborhood to ensure proper safety techniques.

Chinatown Safety Tips

The Chinatown Safety Quiz should be completed by each student planning on serving in the Chinatown community.

Chinatown Safety Quiz

CSUMB Release of Liabilty

This is used when service learners are asked to participate in activities or events not tied to a course on or off campus.

CSUMB Release of Liability Form

Risk Management Principles

The following guiding principles are considered best practices throughout the field and apply to all the parties involved in service learning experiences.

Since each service learning course is different, these guidelines are not intended to be all encompassing. However, these do's and don'ts apply to most situations.

Guiding Principles to Reduce Risk in Service Learning

SLI Equipment Checkout

The SLI has a variety of equipment to assist in capturing media (flip cameras, camcorders, & digital cameras etc). SLI faculty and students enrolled in a SL course or working on Service Learning Capstone are welcome to use this equipment.

Please read the second page for details regarding home use responsibilities. Please note a faculty signature/consent is required prior to equipment being loaned out.

SLI Equipment Checkout Form