Service Learning Application Form

Service learning requires a minimum commitment of 20 hours and will appear on your transcript as MEDI 2612.

Registration for this program is only available to Med 2 students at this time.

The Service Learning Leadership Committee will review applications and match students to community organizations.

Complete the attached application form and submit to Sarah Peddle.


Applicant Contact Information




 Weekday mornings
 Weekday afternoons
 Weekday evenings
 Weekend mornings
 Weekend afternoons
 Weekend evenings


Top three Service Learning Experience Choices

Please tell us, in order of preference (1 being the most preferred), which service learning experiences you are most interested in.

Please indicate the organization name and the project number (if applicable)



Special Skills or Qualifications



Person to Notify in Case of Emergency



Agreement and Signature

I understand that participating in this program means that I am representing the medical school in the community and will conduct myself in a professional and courteous manner.