First Name

Last Name

Select Gender MaleFemale

Transfer Student YesNo

Have you completed the Academic Seminar? YesNo

Is this your first year at Franciscan Missionaries of Our Lady University? YesNo

Please list your certifications:

Address

Zip Code

Primary Phone

Secondary Phone

High School Attended

Course Name and Section Number:

Instructor

Have you previously participated in any type of volunteer service, community service or service-learning? YesNo

Informed Consent:Directions: Please read each statement below carefully. Please check each statement you consent to. I give Franciscan Missionaries of Our Lady University permission to publish my picture and/or quote in University materials, such as newsletters, brochures, etc…for the purpose of marketing/advertising.I give Franciscan Missionaries of Our Lady University permission to use/analyze my reflection assignment or other class material(s) for the purpose of conducting educational research, presenting and national and/or international conferences outside of Franciscan Missionaries of Our Lady University. I understand that I will not be identified and my personal information will not be disclosed.I give Franciscan Missionaries of Our Lady University permission to use/analyze any surveys I complete for the purpose of data presentation, program evaluation and modification. I understand that I will not be identified and my personal information will not be disclosed.

Student Signature:

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Service Learning Student Volunteer Demographics Form