Iowa Wesleyan College

Retroactive Form (24 and older)

Persons who are 24 years of age or older when they begin as an Iowa Wesleyan College degree seeking candidate, and who have extensive experience in volunteer service prior to enrollment at Iowa Wesleyan College, may petition for retroactive units in place of all or part of the service unit component. Such service must be verified, documented and approved by the Director of SL. Please complete the Retroactive Form below and click “submit” to send your form automatically to The Center for Service-Learning & Civic Engagement for review. In addition to this form you MUST submit a letter of verification from each service agency verifying your total hours and dates. (Please see the example letter of verification under “Student Resources” section.)  

NOTE: Students on the new program who are approved for full or partial retroactive units must enroll and complete SL 300.  

 

 

Today's Date:
First Name:
Middle Name:
Last Name:
IWC Email:
Address:
Home Phone:
Cell Phone:
Names and addresses of the agencies, institutions or situations which you served:
Name
Address
Names and phone numbers of the supervisors or contact persons with whom you worked:
Name
Phone
Briefly discuss your duties and responsibilities for each service project:
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
When did your project begin and end? (Example: May ’95 through April ’98) How many hours for each project?
Begin
End
1.
2.
3.
4.
Total Hours
Did you receive pay or remuneration for your services?
Yes
No
Are you currently involved in any volunteer work:
Yes
No
If yes, please explain:
. Academic Honesty: By electronically signing your name and submitting this Retroactive Form, you attest that all
information is accurate and truthfully reflects your previous service. Please reference Iowa Wesleyan College’s
Academic Honesty Policy found in the Student Handbook (Page 10).
Name:
* * * * *