Service Learning Basic Information Form

Today's Date:

Advisor:

First Name:

Middle Name:

Last Name:

Your major(s)/minor(s):

When did you start at Iowa Wesleyan College?:

(Semester)

(Year)

(I.E. Junior Transfer, Freshman, etc.)

Your current academic status and program schedule (check all that apply):

You expect to graduate in:

If you are a residential student, please list your campus address and the phone number:

Residence Hall & Mailbox #:

Phone:

For both residential and non-residential sudents, please list your permanent home address and phone number:

(Street, Apt. No.)

Phone:

(City)

(State)

(Zip)

IWC Email Address:

(Correspondence sent to IWC Account)

If you are currently employed, give your place of employment and the phone number at which you can be reached:

(Name of Employer)

(Telephone Number)

Have you initiated or completed your Field Experience Requirement? If so, where did you complete your internship or what stage are you in?

(Country)

Gender:

Male

Female

Student ID#: