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Turn this form in to your instructor, no later than a week before the end of the semester.

Student

Name______________________________________________________

Course Title___________________________________ Course :Number________

Email _____________________________

Name of agency where you are doing service-learning_____________________________________________________________

Requirements: You must serve the minimum number of hours required by your instructor no later than a full week before the end of the semester.

Date:
Time In:
Time Out:
Total Hours:

TOTAL HOURS_______________

Student Signature___________________________________ Date___________

On-Site Supervisor__________________________________ Date___________