* = Required Field
Student's First Name:* Last Name:*
Student's ID Number:*    
Street Address:*
City:* Zip Code:*
E-Mail * Phone Number*
Current CBL Course:

Instructor's Last Name:*

5-digit Section Number:*  
Course Name and Number :*
                                      (example: Bio 106, Eng 101, Hist 112, Polisci 150)

Service Option

Research Option


Number of hours required to complete this project is: * .


List topics of community interest in which you would like to participate: *
The following information requested will provide the Community-Based Learning office with valuable information to help further develop the Community-Based Learning Program at College of the Canyons. No personal information will be given to any third party.
Student Data:
Date of Birth
(Ex. 01/01/83)*
 Sex  Female        Male      Decline to State    
Ethnic Identification:
African- American American Indian/Alaskan Native
White/Caucasian Non-Latino/Hispanic Filipino
Asian Latino/Hispanic Pacific Islander
Decline to State Other Non-White
Units enrolled in this semester:
Units completed to date:    
Overall g.p.a.    
Please check one: *
I plan to transfer/graduate at the end of this semester
I plan on continuing my education at College of the Canyons next semester
Expected transfer/graduation date: (Ex. 01/01/83)
Academic Major:      Career Goals:
Languages you speak other than English:
Do you have any previous service or volunteer experience? * Yes     No
If yes, how many different agencies?
If yes, (approximately) how many total hours?
List agencies you have volunteered for in the past:
List skills you acquired from volunteering:

Disclaimer for Community-Based Learning (CBL) Students:

It is the students’ responsibility to properly enroll in the Community-Based Learning Program.  If the student wishes to drop from the program at any given time, it is the student’s responsibility to contact the CBL Staff. Also, if you are participating in CBL for multiple classes you are responsible to complete all the required components for each class unless otherwise arranged by the Community-Based Learning office. If you have any questions or concerns throughout the process feel free to contact us at (661) 362-3231 or email us at

I will conduct myself in a professional manner with respect for others, and abide by all College regulations as outlined in the Student Conduct Code.

By clicking the submit button below, I agree to the terms of this agreement, and to complete the required assignments.