Download Service-Learning Certification Form

Service-Learning Certification Form
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SECTION 1
Instructor(s):
Leadership
Department:
Course: Leadership
Level(s): 9-12
Period(s) Participating:
Grade
School:
Department:
Anticipated # of students:
Grade Level(s):
Project Name: Adopt-A-Grandparent Day
Date Submitted:
Anticipated # of
students:
SECTION 2 Project Description:
Students plan & host a day of entertainment, food, & friendship for the local residents from several
convalescent homes & elderly day care facilities. Through a buddy up/interview process the visitors
& students participate in a two-way dialogue about each other’s lifestyles & cultural backgrounds.
Food provides one method of cultural exchange by a student/community provided buffet. Students
research dietary needs & restrictions of their visitors when deciding on what to serve, blending their
cultural favorites into this restricted menu plan. Entertainment is provided by a variety of student
groups
SECTION 3 Community Need(s):
Many of the elderly in nursing homes have little contact with the “outside world” or young people.
Contact with youth is as vital to them as it is for our young people to be in contact with the elderly.
Adopt-A-Grandparent Day is an enrichment activity that provides a means for both generations to
further their understanding of each other’s lifestyles, music, & forms of entertainment. The event
provides an opportunity for cross-generational communication & cultural understanding
SECTION 4 Community Partner(s):
Local senior citizen home, local groceries
SECTION 5 Student Voice
Students:
 decide which facilities to contact and invite.
 decide which places to contact for donations of food
 decide forms of student entertainment, and invite those groups on campus to participate.
 decide who will buddy up with the visitors for the day.
create the agenda for the day’s activities.
SECTION 6 California Content/Skill Standard(s)
California Association of Directors of Activities (CADA) Standards:
Strand 1: Communications
Standard 1: Written Communication
Standard 3: Public Speaking
(OVER)
SECTION 7 Project Components:
Student will:
 complete proper activity approval forms.
 write an agenda for the day’s activities.
 create planning sheets, including a phone/address list of facilities, organizations, potential
donation sources, & entertainment available on campus from various student groups.
 make a RSVP list and decide who will buddy up with the visitors for the day.
 write letters of invitation & business letters asking for donations.
 devise a food donation pick up schedule & work w/administration regarding parking.
 design an interview booklet to be used with the buddies.
 research dietary needs and restrictions of the visitors when deciding on what to serve,
blending their cultural favorites into this restricted menu plan.
 ensure their event is reported in the school newspaper.
 decorate the room and set up the food.
 write thank you letters to participates & people/organizations who donated
time/food/funding.
The class historian will include pictures of the event in the Leadership Scrapbook.
SECTION 8 Reflection Prompts
In their after-action report, students will reflect on their role in planning the event and its execution.
Their reflections will include suggestions for improvement for next year both for their performance
as well as ideas for the event in general.
SECTION 9 Outcomes and Assessments:
Each student committee member will evaluate the co-chairpersons of the event using a rubric.
Each student committee chairperson will evaluate the committee members using a rubric.
SECTION 10 Accommodations/Support for Diverse Learners:
 Appropriate tasks will be assigned to all students.
 Students will be encouraged to work collaboratively and respect the talents of each of the members of
their group.
 Locations will be accessible. When not available alternative sites will be sought.
 Each group member will have equal opportunities to make significant contributions to the project.
 Students with IEPs will be identified and individual needs will be addressed.
I agree to the above accommodations for diverse service learners. Initials______
SECTION 11 Administrator Comment(s) / Recommendations:
Submitted by: ____________________________________________
Teacher Signature
Date: _____________
Approved: ________________________________________________ Date: _____________
Principal or designee Signature
Original to: _____APSCS
Copies to: _____SIS Coordinator
_____Teacher(s)