School Hosted Student Service Learning (SSL)
Opportunity—During the School Day
Ofﬁce of Student and Family Support and Engagement
MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS)
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