EXPERIENTIAL LEARNING REPORT FORM PART A: PLANNING

Office of the Registrar

INSTRUCTIONS:

At Knox, Experiential Learning refers to learning that occurs through intentional and planned activities outside the traditional classroom which can contribute to professional and/or personal growth. The project is completed in three stages:

1. a plan, developed in advance and approved by the faculty or staff project sponsor;

2. the project itself, involving at least 40 hours of activity;

3. a reflective essay written at the conclusion of the project.

Part A of this form should be e-mailed to and signed by the academic advisor (or other sponsor) prior to the experience. Both parts A and B must be e-mailed to the Office of the Registrar at registrar@knox.edu after completion of the project. Students who enter Knox after significant adult work experience that seems appropriate as “Experiential Learning” may talk with their advisor about working on a retrospective reflection.

THIS PART OF THE FORM IS TO BE FILLED OUT PRIOR TO THE EXPERIENCE.

Date: Select today’s date.	Student ID#: Enter ID number here.
Student Name: Enter name here.	Dates of Experience: Enter dates of experience here.
Term and Year of your expected graduation: Term / Year
Academic Advisor Name: Enter name of academic advisor here.
Sponsor Name (if different from advisor): Enter sponsor name here.

Type of Experience (select one):

Internship

Work experience

Community service

Off-campus study: Name of program: Enter name of program here.

Study abroad

Study in the U.S.

Independent research/creative work

Teaching assistantship

Campus leadership experience

Other experience (please specify): Specify here.

Brief description of planned experience:

Type your answer here.

What was your primary reason for choosing this experience? (select one)

Academic/professional growth

Personal growth

Intellectual curiosity

What are your objectives in participating in this experience?

Type your answer here.

Authorizing signature of student: Student sign here.	Date: Select today’s date.
Authorizing signature of sponsor: Sponsor sign here.	Date: Select today’s date.

EXPERIENTIAL LEARNING REPORT FORM PART B: REFLECTION

Office of the Registrar

THIS PART OF THE FORM IS TO BE FILLED OUT AFTER THE EXPERIENCE.

Student Name: Enter name here.	Student ID#: Enter ID number here.
Dates of your experience: From Select start date. to Select end date..

Provide a brief description of the experience (ca. 150-250 words).

Type your answer here.

How valuable was your experience to your academic/professional growth?

Not at all valuable

Somewhat valuable

Moderately valuable

Very valuable

How valuable was your experience to your personal growth?

Not at all valuable

Somewhat valuable

Moderately valuable

Very valuable

How valuable was your experience to your intellectual development?

Not at all valuable

Somewhat valuable

Moderately valuable

Very valuable

To what extent has the experience helped provide you a sense of direction for your life after Knox?

Not at all helpful

Somewhat helpful

Moderately helpful

Very helpful

Reflect on how the experience went, what you learned from it, and how it may influence your future academic or personal life. Some things you might consider include: What was the most valuable part of the experience? What difficulties did you face and how did you respond to them? To what extent were your expectations going into the experience met? What previous experience or study contributed to the success of your experiential learning project? Was there any additional preparation that would have been useful? If you were doing this again, what might you do differently? (ca. 500-750 words).

Type your answer here.

Authorizing signature of student: Student sign here.	Date: Select today’s date.
Authorizing signature of sponsor: Sponsor sign here.	Date: Select today’s date.