Service Hours Verification Form
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1LEAD Scholars Academy
S
H
V
F
ERVICE
OURS
ERIFICATION
ORM
Student Name: ________________________________ Year: 1
st
or 2
nd
UCFID:____________
Service Project Start Date: _____________
Service Project End Date: _______________
Service Project Title: ___________________________________________________________
Service Agency: _______________________________________________________________
Number of Hours Completed: ________
A) Please provide a complete description of the service performed.
B) Please answer these questions in regards to the service you performed:
What category (or categories) does your service experience represent (select most appropriate)?
___ Youth & Education
___ Mental and Physical Health
___ Alternative Break Program
___ Hunger and Homelessness
___ Animals
___ Campus Leadership
___ Environment
___ Social and Justice
___ Gender Issues
____
___ Special Needs
___ Spiritual Leadership
___ Other (Describe)
___ Elderly Awareness
________________________________
C) Please circle the response that best answers the following question:
I feel that I positively impacted the community as a result of my volunteer experience.
Strongly Agree
Agree
Disagree
Strongly Disagree
I learned more about my leadership skills as a result of my volunteer experience.
Strongly Agree
Agree
Disagree
Strongly Disagree
D) Student Information:
Student Signature: _______________________________
Phone Number: ____________
Student E-mail Address: ___________________________________ Date: _____________
E) Agency Information:
Authorized Agency Signature: ________________________ Phone Number: ____________
Print Name: _____________________________
Position: _________________________
Authorized E-mail Address: ________________________________
Date: _____________
*Community service hours performed during Winter Break and/or Summer Break will not be counted*
OFFICE USE ONLY:
LSA Board Signature: _________________________
Date: _________
____ Experiment
or
Instructor Signature: __________________________
Date: _________
____ Service Page
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