Return to service learning Web page
STUDENT: ______________________________STUDENT ID #:____________PHONE:______________
ADDRESS: ________________________________ CITY/ZIP____________________________________
AGENCY: ____________________________________________________________________________
AGENCY ADDRESS:_______________________________CITY/ZIP ____________________________
AGENCY SUPERVISOR ____________________________PHONE: _____________________________
SEMESTER YEAR___________ COURSE/SECTION #: __________________
INSTRUCTOR ____________________________________PHONE: ____________________
DATE | MON | TUES | WED | THURS | FRI | SAT | SUN | TOTAL WEEK | RESPONSIBILITIES
| INITAL | ||
| Stud/Inst | ||||||||||||
ENDING DATE_______________________TOTAL HOURS COMPLETED ________________
SUPERVISOR'S SIGNATURE _________________________________________
Students please use this form to record the number of hours per week you serve at the placement site. When you have completed your service hours, return this form to your instructor.
Return to service learning Web page
Direct feedback to: Randy Kimmens
URL: http://www.gc.maricopa.edu/servicelearning/fcontactlog.htm
Last update: Thursday November 02 2000