Community Participation Summary Form

Summary of Prior Learning - Community Participation

This information provides the evaluator with an introduction to your learning. In the interview, the evaluator will ask you questions similar to those given in the Guide to Credit for Prior Learning. If necessary, you and the evaluator may agree on further methods of demonstrating your learning, including a written essay, a demonstration or performance, an examination, or a sample of your work. Please attach appropriate documentation to this form.

You will be charged for your assessment of prior learning based on the IEF or IPLA fee structures as seen on www.esc.edu/fees. If your first matriculated enrollment was January 2012 or later, you may incur additional charges for the submission of Individualized Prior Learning Assessments (IPLAs). If your first matriculated enrollment was prior to January 2012, you must have paid the Individual Evaluation Fee (IEF) before this request can be processed.

Please submit two copies of this form and two copies of any attached documentation to:
CDL Assessment Office, Empire State College, 113 West Avenue, Saratoga Springs, NY 12866.

---

Name:___________________________________________________________ESC ID:______________________

Address:____________________________________________________________

Phone (w)________________ (h)________________ Email Address:________

Mentor/Advisor:__________________________

Please indicate if you are involved in any of the following CDL programs:

____AARP _____AT&T _____Lucent _____United Steelworkers

Credits Requested:________ Level: Intro. or Advanced

Liberal Credit Requested:__________

Check the areas in which you believe you have competence. Identify whether you have an introductory or an advanced level of understanding.

Topic:	Introductory	Advanced
Community: Definitions and Social Context
The Process of Personal Involvement
The Process of Social Change

Please complete the following questions. Use additional pages if necessary.

1. List the community activities in which you have participated and the approximate time in which you have been involved for each activity.

2. List any related training or conferences that you have attended.

3. List reading done related to community participation.

4. What is the most important learning you have acquired about effective community participation?

5. What challenges have you faced in learning about effective community participation?