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Service-Learning Time Log

Use this form to report your service-learning activities and hours.  You may report all hours served even if you were not referred by the LCSC service-learning program.  Contact Charlette Kremer if you have any questions.

Today's Date:

Semester:

Fall
Spring

Year:     

Your contact information:

Name
Phone
E-mail

Agency contact information:

Supervisor Name
Agency
Phone
E-mail

Faculty contact information:

Name
Class
Work Phone
E-mail

Dates of service:

How many hours did you serve?

Supervisor name:

Did you work with any Pre-K to grade 12 students?

Yes No

If yes, how many Pre-K through grade 12 students did you tutor?

How many Pre-K through grade 12 students did you mentor?

Comments:


Funding for this Web site provided by:
 
Revised: 02/08/08

 


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