國立成功大學服務學習課程免修申請表

國立成功大學學年學期從事志工、志願服務免修服務學習課程申請表

National Cheng Kung University
Service Learning Credit Exemption Application Form

Year ____ Semester ______

學系：　　　　　　　班別: __________姓名：　　　　學號：______________申請日期：　年　月　日

Department : __________ Class : __________Name : __________________ Student ID: ________ Date : dd ____mm____yy____

編號 No.	服務機關名稱 Service Agency	服務內容 Service Content	事前申請 Prior application 教學單位核章 Department Chair signature	服務時數 Service Hours		檢附證明（正本） Document (Original)		備註 Remark
編號 No.	服務機關名稱 Service Agency	服務內容 Service Content		申請時數 Credit Hours Applied	核准時數（審核人員填寫） Credit Hours Approved (Written by Auditor)	服務證明 Proof for service	反思心得 Self-Reflection Review	備註 Remark
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免修科目：□服務學習（一）□服務學習（二）□服務學習（三） Exempted Course : □Service Learning（1） □Service Learning（2） □Service Learning（3）				審核人員：　　　　　　教學單位主管： Audited by : Department Chair:
審核通過總時數：　　　小時符合規定：是□　　否□ Approved Total Hours : _________ Provision Compliance : Yes□ No □				審核人員：　　　　　　教學單位主管： Audited by : Department Chair:

備註：

一、學生從事志工或志願服務，若欲抵免服務學習課程，應事先取得本系系主任之同意。

二、申請抵免服務學習課程，其志工或志願服務證明須以在學期間為之，其服務時數須達18小時以上且須附上反思心得報告。

三、依「國立成功大學服務學習課程實施辦法」第七條規定：「…學生於寒暑假或課餘時間，從事志工服務而取得政府機關或立案之慈善、醫療等機構開立至少18小時以上時數證明，或修習融入服務學習內涵之通識課程或專業課程及格且實際服務時數至少8小時以上者，經教學單位主管同意後，得申請免修服務學習課程。相關免修規定，由各教學單位自行訂定。」

四、本申請表經教學單位主管審核同意簽章後，送教務處註冊組辦理抵免事宜。

Remarks :

Student who works as volunteer and wants to exempt Service Learning courses must get Department Chair’s approval beforehand.
The volunteer service hours should be laid within study period. The min hours should be at least 18 hours.

When applying course exemption, student should submit self-reflection review.

According to “Implementation Regulations for Service Learning Courses”Article 7:

Students who have received a certificate of a minimum of 18 working hours from a volunteer program for a government-run or government-registered charity or medical institution during a winter or summer break or on extracurricular occasions, or those who have completed a service-learning oriented general knowledge or specialized course with a minimum of eight hours of actual service participation may apply for equivalent course waiver, which shall be approved by the department chair. All departments shall formulate regulations governing the waiver accreditation of service-learning hours.

After student gets the approval of Department Chair, student should submit this form to Office of Academic Affairs to apply course exemption.

「服務學習反思心得」

Service Learning Self-Reflection Review

姓名

Name

系級

Department / Grade

服務日期及時間

Date and Time

合計時數

Total Hours

小時

Hours

服務地點及機構

Place and Organization

心得內文(請自行增列所需頁面，至少500字並附2張活動照片)

Self-Reflection Review (Add more pages if needed. At least 500 words and two photos.)

What （學習了什麼？）--我做了什麼？看見什麼？聽到什麼？接觸了什麼？

What (What do I learn?) – What do I do, see, listen, and touch?

2. So What（所以，為什麼）-我的所見所聞帶給我什麼感想與思考？我學到什麼？對我有什
麼意義？服務過程中，我產生了什麼新問題？

So What (So, why?)--- What do I get from this experience? What do I learn? What is the influence on me? During service period, what problem do I find?

3. Now, What（現在我可以如何去做？）這些經驗對我看事情、看世界、看自己有什麼改變？我能做什麼？對我看社區服務及社會正義有什麼影響或改變？服務過程中對我而言最有價值的部分為何?

Now What (Now what can I do?) From this experience, how it enables me to evaluate things in this world, myself? What can I do? I there any means or change for me to evaluate social service and social ethics? What is the most valuable part of this service?

評

評閱者：_______________________

閱者：

Checked by: ______________