SERVICE Certificate Program Hours Report

This form is designed so that you can submit your service learning hours online for verification and approval purposes. All hours will be reported in consideration for the Service Learning Certification.

Term

Ex. Fall 2020
Name Name First Last
T Number
Email
Service Learning Certification Program

Service Learning Certification Program Undergraduate Program Graduate Program
Major and Department

Example: EXPW, Education
Name of Faculty Member Overseeing Service Being Reported

This is the faculty member that will have to approve your hours in consideration for the SL Certification Program
Name of Course if Service is Part of a Course

Skip item if not part of a class.
Name or Description of Service Hours Being Reported

Ex. Habitat for Humanity
Ex. Fall Fun Festival
Ex. I collected books for Jere Whitson Elementary School
Name, Phone Number and Email Address for the Direct Supervisor of Your Service Hours Being Reported

Could be the director or volunteer coordinator for an event or at a nonprofit agency. Could also be the same approving faculty member.
My signature, below, signifies that all information reported above is accurate and truthful.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Reflect on the service you did this term. Use the box below to write a summary, your take away from the experience. What did you learn? What skills did you gain? How do you feel you impacted the community?
How many hours of service did you complete through this course?