Mcps Form 560 50 – Fill Out and Use This PDF

MCPS Form 560-50

August 2021

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Individual Student Service Learning (SSL) Request

STUDENT INSTRUCTIONS: This form is for students to pursue a Student Service Learning (SSL) opportunity that is not identified on the Montgomery County Volunteer Center (MCVC) website. The names of registered nonprofit organizations that have certified compliance with MCPS Guidelines

for SSL can be found on www.montgomeryserves.org. Students should be familiar with the Seven Best Practices of Student Service Learning www. montgomeryschoolsmd.org/departments/ssl/pages/bestpractices.aspx. Students should complete this form by typing into this interactive form, or print legibly in blue or black ink, obtain parent/guardian approval, and submit it to their school-based SSL coordinator at least 2 weeks prior to starting the SSL activity.

STUDENT FOLLOW UP (if activity meets MCPS Guidelines for SSL after review by the MCPS SSL coordinator—see MCPS guidelines at www.mcps-ssl.org): Documentation of all service is due to the school-based SSL coordinator must be completed on MCPS Form 560-51, Student Service Learning Activity Verification Form, by the recommended or REQUIRED dates below: (please note that all SSL hours are available on StudentVUE portal after they have been verified by the school-based SSL coordinator. In order for the SSL hours to be reflected on the student’s report card, the dates below must be met.)

Service completed during the summer—Recommended by Last Friday in September

Service completed during the summer and 1st semester—Recommended by First Friday in January

Service completed during the summer, 1st semester, and 2nd semester to be recognized for the Certificate of Meritorious Service (high school seniors) or the Superintendent’s SSL Award (middle school)—REQUIRED by First Friday in April

Service completed during the summer, 1st semester, and 2nd semester—REQUIRED by First Friday in June

ALL SSL Forms for service completed any time during the current school year, including the summer before the current school year, are REQUIRED to be submitted to the school SSL coordinator no later than the first Friday in June.

STUDENT INFORMATION—To be completed by the student at least 2 weeks prior to beginning the volunteer activity.

Student Name (Last, First, Middle)_____________________________________________________________ Student ID _________ Grade _____

School -- Choose One --First Period Teacher_____________________________________________

Email______________________________________________________________________________________________________________________

Parent/Guardian Name__________________________________________Phone: Home or Cell _____-_____-______  Other _____-_____-______

Name of registered nonprofit organization that is NOT listed as MCPS SSL (those nonprofit organizations who have certified compliance with MCPS Guidelines for SSL) on the MCVC website, and student is requesting to volunteer with:__________________________________________

Name of nonprofit supervisor:______________________________________________________________________________________________

Service activities to be done include (please provide a detailed description of the volunteer service/activity you will be doing with this organization):

Proposed dates of service:  From ____/____/_____  To  ____/____/_____. (Maximum 1 school year)

Student Signature_______________________________________________________________________________________Date ____/____/_____

GUIDELINES FOR STUDENT SERVICE LEARNING (SSL)

This form must be completed and submitted to the school SSL coordinator PRIOR to the student beginning a volunteer opportunity for which SSL hours are desired with an organization that is not identified on the current list of nonprofit organizations that have certified compliance with Montgomery County Public Schools (MCPS) Guidelines for SSL. This list can be found on the MCVC website at www.montgomeryserves.org. Please allow 2 weeks for the SSL Coordinator to review this request. The following guidelines must be met by the registered nonprofit organization named on this form in order for the student noted on this form to participate in an SSL activity with this registered nonprofit organization.

DISTRIBUTION: Copy 1/School-based Student Service-Learning Coordinator; Copy 2/Student

MCPS Form 560-50

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GUIDELINES FOR STUDENT SERVICE LEARNING (SSL) (continued)

NONPROFIT ORGANIZATION INFORMATION AND CERTIFICATION—To be completed by the supervisor

Organization Name__________________________________________________Federal Employer Identification # __ __ - __ __ __ __ __ __ __

Address  Street_ ________________________________________________ City_______________________ State ____ Zip Code ____________

Phone _____-_____-______  Fax _____-_____-______  E-mail_____________________________________________________________________

Secular activities (activities that have no religious or spiritual basis) to be performed by student include (please provide a detailed description of the services/activities the student is expected to perform):

My signature below certifies and vertifies that:

•I am 18 years old or older.

•I agree to the MCPS Guidelines for SSL noted above.

•I agree to supervise the student in the above activities in a public place.

Name (Print)___________________________________________________________________ Title______________________________________

Signature_______________________________________________________________________________________________ Date ____/____/_____

PARENT/GUARDIAN APPROVAL: My signature below verifies that:

•I approve and accept full responsibility for my child’s participation in this SSL opportunity with this organization.

•I know this request must be submitted to, and reviewed by, the MCPS SSL coordinator prior to my child beginning the activity.

•I understand that the organization with which my child will be volunteering is not listed on the MCVC website, but has submitted certification of compliance with MCPS Guidelines for SSL.

Parent/Guardian Name (Print)__________________________________________ Signature__________________________Date ____/____/_____

APPLICATION REVIEW BY SSL COORDINATOR

oOrganization has certified compliance with MCPS SSL Guidelines as detailed above 

oOrganization has not certified compliance with MCPS Guidelines for SSL

o Other (explain) ______________________________________________________________________________________________________

Signature, Coordinator, Student Leadership and Volunteers_ __________________________________________________ Date ____/____/_____