銘傳大學服務學習校內實作申請表

銘傳大學服務學習認證型校內單位實作服務申請書 Ming Chuan University Recognition of Service-Learning atOn-campus Units- Application Form			申請日期Application Date: 年(Y) 月(M) 日(D)
申請者資料Information Regarding Applicant
姓名Name		學號Student ID No.
系級Class		聯絡電話Contact No.
服務單位資料Information on Service Organization
單位名稱Unit Name		服務地點Venue
服務對象Population Served	□校內人員On Campus Persons □校外人士Off Campus Persons	督導簽章Supervisor’s Signature
服務期間Service Date	自From 年(Y) 月(M) 日(D)至to年(Y) 月(M) 日(D)，共計小時hour in total
服務內容Service Duties and Responsibilities

服務單位審議結果Evaluation Results of Service Unit
(請蓋單位章) (Unit Stamp) □同意申請人至本單位實作服務，並依單位要求督導該生 I agree to allow applicant to provide services at this unit and will provide supervision in accordance with the requirement. □不同意Rejected (請將此申請書交至前程規劃處) (This application must be submitted to Career Development Center)
前程規劃處認證及畢業門檻資訊 Verification of Career Planning and Counseling Division and Graduation Requirements Information
◆ 收件日期Date of Application：年(Y) 月(M) 日(D) ◆服務學習需完成：Service Learning Requirements 服務學習時數16小時16 hours of Service 服務學習反思報告1份One Service-Learning reflection report 服務學習專題講座1場One Service-Learning Lecture 服務學習成果發表會1場One Service-Learning Experience Sharing ◆服務學習列為畢業門檻，上列四個項目皆須完成才符合畢業資格喔！ The above four items must be completed before graduation. ◆所有參與紀錄皆可在學生資訊系統>e-Portfolio>「服務學習」查詢。 All records can be checked in the Student Information System > Student’s e-Portfolio > Service-Learning. ◆服務學習辦公室地點Service-Learning Office：台北校區：行政大樓2樓(分機2401)桃園校區：社科大樓Ⅱ(原管理大樓) S212(分機5089) Taipei campus: A building 2F (Ext.2401)Taoyuan campus: S building S212 (Ext.5089)

【個資宣告】此資料之蒐集僅限於學生資料管理、教育或訓練行政、志工管理、社會服務或社會工作、協助公部門調查或執行業務及法令需求等目的使用，非經當事人同意，絕不轉做其他用途，亦不會公佈任何資訊，並遵循本校資料保存與安全控管規定辦理。(詳細個資管理可參閱「銘傳大學個人資料保護管理要點」與「銘傳大學個人資料保護專區」http://pims.mcu.edu.tw)

The information collected is only for the purposes of student information management, educational or training administrative affairs, volunteer management, social service or social work, assisting public sector entities with investigation, operations, and legal obligations set in accordance with relevant regulations. Career Planning and Counseling Division processes information according to Ming Chuan University (MCU) information maintenance and security management regulations. Career Planning and Counseling Division shall not disclose or provide any information to any third party without prior consent, nor transfer information for any other uses. (For more details on personal information management, please refer to MCU Guidelines for Personal Information Protection Management and MCU Personal Information Management System at URL http://pims.mcu.edu.tw.)

銘傳大學學生參與校內外服務工作服務時數紀錄表

Ming Chuan University Student On- or Off-Campus Service Hours Records

姓名Name：系級Class：學號Student ID No.：

日期 Date	服務時段 Service Period (00:00~00:00)	服務時數 Service Hours	服務內容 Service Duties and Responsibilities	督導簽名 Signature of Supervisor	備註 Note
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合計Total	小時Hours		督導評語(Commentary)：督導(Supervisor)：(簽名)（Signature）

＊此表填寫完後，請擲交回服務學習辦公室 After filling out this form, please submit it to the Service-Learning Office.