Community-Based Learning Information Form
Please complete the following items and click submit. These records are required by Mason's legal counsel and will be shared with your course instructor to help facilitate easy communication with you and your community partner.
Student Name
Your answer
Student Email
Your answer
Student Phone
Your answer
Course Number (e.g. NCLC 303)
Your answer
Professor(s) Name
Your answer
Organization (Agency) Name
Your answer
Supervisor Name
Your answer
Supervisor Title
Your answer
Supervisor Email
Your answer
Supervisor Phone
Your answer
Start Date (Format: 04/11/2012)
Your answer
End Date
Your answer
Number of Hours to be completed
Your answer
Please provide a brief description of the service project you and your supervisor have agreed to.
Your answer
Submit
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