School Hosted Student Service Learning (SSL)
Opportunity—During the School Day
Office of Student and Family Support and Engagement
Rockville, Maryland 20850
This form is for school staff to provide a Student Service Learning (SSL) opportunity to middle or high school students during the
school day. The school must ensure that the service is for a non-profit organization that is registered with the Montgomery County
Volunteer Center, and has completed MCPS form 560-51A, Organization Responsibility and Assurance Certification Document. The
school is expected to provide explicit instruction on the mission of the non-profit organization and the impact the students’ service
would have on the community served by the non-profit organization.
To be completed by the school at least 1 month prior to beginning the service learning activity.
School Name __________________________________________________________________________________________________________
Staff Member Completing Form: Name _________________________________________________Position___________________________
Grade Level(s)/Class(es) that will be participating __________________________________________________________________________
Number of students expected to participate _______________________________________________________________________________
Name of Non-Profit organization(s) ______________________________________________________________________________________
Corresponding Non-Profit organization(s) Federal Employer Identification # _________________________________________________
Community need that the non-profit serves _______________________________________________________________________________
Describe the Instruction provided to students to highlight the non-profit organization and the purpose of their service:
Description of the event:
When/How will student reflection occur:
School/Administrator Approval: My signature below verifies that:
The school is responsible for obtaining the materials necessary for students to complete the SSL project and for delivering
any items created as a result of the SSL project to the rightful non-profit organizations, e.g. making sure that items made for
residents in a nursing home are delivered to the nursing home.
The school will identify a staff member to add the SSL hours earned to the appropriate student records.
I know that this request must be submitted to (no later than 1 month prior), reviewed by, and approved by the MCPS SSL
coordinator prior to the beginning of the SSL activity.
Name of Staff Member (Print) __________________________________ Signature___________________________Date ____/____/_____
Name of Principal (Print) _______________________________________ Signature___________________________Date ____/____/_____
MCPS Form 560-59
August 2018
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