MCPS Form 560-50: Individual Student Service Learning (SSL) Request

Section I, Student Information, is to be completed by the student.

Enter the Student Full Name and the Student ID.

Choose your School from the list, then enter the First Period Teacher, the Grade and the Email.

Enter the Parent/Guardian Name and the Phone: Home or Cell.

Section II, Community Organization Information (including faith-based agencies or institutions), is to be completed by the adult representative of the community organization.

Enter the Organization Name.

Enter the Federal Employer Identification # for tax-exempt organizations.

Enter the Address: Street, City, State and Zip Code.

Enter the Phone and the Email.

Initial to verify that you understand and agree to the following guidelines that must be met in order for the student noted on this form to participate in an SSL opportunity with your organization.

Meet the Maryland Seven Best Practices of Service-Learning.

Supervision: Provide ongoing supervision for MCPS students either directly or through appropriately authorized adult designee(s).

Expectations: Advise students of the need that will be addressed by this service, overall expectations, and safety information.

Liability: Maintain general liability insurance that covers MCPS student volunteers.

MCPS students MAY NOT earn SSL hours for: door-to-door distribution or neighborhood canvasing of any kind; service supervised by parent or relative; service without sponsorship of an approved community organization; service supervised by an individual who is younger than 18 years of age; service performed on private property or in a private residence/home (unless a virtual/remote opportunity specifically approved by the MCPS SSL office); service that replaces a paid staff worker of the participating agency; service resulting in money, goods, services, or other compensation.

Logs: Maintain a log and verify student service on MCPS Form 560-51, Student Service Learning Activity Verification according to program timelines.

Awarding of Hours: Award one (1) SSL hour for every hour of service, not exceeding eight (8) hours within a 24-hour period.

Business Relationships: The following MAY NOT be counted towards the service-learning graduation requirement: any service with the chief purpose of increasing the amount of revenue for a private, for-profit business or to generate new revenue for that business; any service that replaces a paid staff worker of the participating agency or institution with a student earning service-learning credit; any service that compensates a student with money, goods, services, or other compensation.

Ethical Conduct with Students: Build positive relationships with MCPS students to support learning and adhere to standards of professional practice, including, but not limited to, provisions of the MCPS Employee Code of Conduct regarding appropriate conduct with students, available on the MCPS website: www.montgomeryschoolsmd.org.

Sex Offenders: Shall not knowingly employ a registered sex offender at the site where an MCPS student is placed.

Compliance with Applicable Laws: Comply with labor laws including the Fair Labor Standards Act, 29 U.S.C. Chapter 8; and all other applicable federal, state, and local laws and regulations, including, but not limited to, those that prohibit discrimination, verbal abuse, threats, physical violence, or sexual harassment directed at others.

Section III, Service-Learning Information, is to be completed by the adult representative of the community organization.

Academic Preparation: Describe how you will teach students about your community organization and the community need that they will address.

Service Action: Check the type(s) of service: direct service, indirect service, advocacy service.

Describe the service activity students will carry out to address the identified community need.

Enter the Proposed dates of service, From and To (Maximum 1 school year).

Enter the Location of service.

The signature of the adult representative of the Organization certifies and verifies that all individuals who supervise MCPS students participating in SSL opportunities with this Organization are 18 years old or older.

The signature of the adult representative of the Organization certifies and verifies that all individuals who supervise MCPS students participating in SSL opportunities with this Organization will supervise the student completing the activities in Section III in a public space, such as organization-owned property, and not in or at a private residence.

The signature of the adult representative of the Organization certifies and verifies that all individuals who supervise MCPS students participating in SSL opportunities with this Organization will adhere to the MCPS Guidelines for Student Service Learning stated on this form.

Print the Name and the Title, then add the Signature and the Date.

Parent/Guardian Approval: My signature in the Parent/Guardian Approval signature box verifies that I approve and accept full responsibility for my child's participation in this SSL opportunity with this organization.

Parent/Guardian Approval: My signature in the Parent/Guardian Approval signature box verifies that I know this request must be submitted to, and reviewed by, the MCPS SSL coordinator prior to my child beginning the opportunity.

Parent/Guardian Approval: My signature in the Parent/Guardian Approval signature box verifies that 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 the MCPS Guidelines for SSL.

Parent/Guardian Name (Print), Signature and Date.

Application Review by Student Service Learning (SSL) Coordinator: Organization is a nonprofit and has certified compliance with MCPS Guidelines for SSL; Organization is NOT a nonprofit, has certified compliance with MCPS Guidelines for SSL, and this request has been approved by the central office MCPS SSL staff; Organization has not certified compliance with MCPS SSL Guidelines for SSL.

Explanation; Signature, Coordinator, Student Service Learning; Date.

Submit this form at least two weeks before beginning the opportunity.

Obtain parent/guardian approval, and submit this form to your school's SSL Coordinator.

This form is for students who want to earn Student Service Learning (SSL) hours with a community organization (including faith-based agencies or institutions) that is not listed as an approved MCPS SSL Organization on the Montgomery County Volunteer Center (MCVC). A list of organizations that are already SSL approved can be found at www.montgomeryserves.org. To qualify towards the state graduation requirement, all Student Service Learning (SSL) opportunities must meet the Maryland Seven Best Practices of Student Service Learning and must include the three core components of service-learning: Academic Preparation, Service Action, and Structured Reflection.