SECTION 1

* Instructors

* School

* Course

* Department

* Period(s) Participating

* Grade Level(s)

Project Name

* Anticipated Number of Students

* Date Submitted

SECTION 2

* What need is being addressed?   (Fill out form and include Project details)

* Who is the community partner?   (Fill out form and include Project details)

* Describe the service taking place:   (Fill out form and include Project details)

SECTION 3

* Content standard(s) addressed:

How is it being assessed?

* Has there been any reflection activity?   Yes No

SECTION 4

Accommodations/Support for Diverse Learners:   � Appropriate tasks will be assigned to all students. � Students will be encouraged to work collaboratively and respect the talents of each of the members of their group. � Locations will be accessible. When not available alternative sites will be sought. � Each group member will have equal opportunities to make significant contributions to the project. � Students with IEPs will be identified and individual needs will be addressed.

I agree to the above accommodations for diverse service learners. Initials

SECTION 5

Teacher Comments and Recommendations