Fillable CIVIC ENGAGEMENT TIME SHEET (State University of New York College at Brockport)

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CIVIC ENGAGEMENT TIME SHEET (State University of New York College at Brockport)

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CIVIC ENGAGEMENT TIME SHEET
Office of Student Conduct
The College at Brockport
Student Information Placement Information
Name: ______________________________________ Site: _________________________________________
Address: ____________________________________ Address: ______________________________________
Phone #: ____________________________________ Phone #: ______________________________________
Hours Required: ______________________________ Supervisor: ____________________________________
Date Assigned: _______________________________ Email: ________________________________________
Due Date: ___________________________________
STUDENT: In accordance with the decision you received, please contact the Office of Student Conduct to schedule a
meeting to determine the site at which you will complete your civic engagement hours by the deadline indicated above.
When your hours are complete, you MUST have your site supervisor sign this form. It is YOUR RESPONSIBILITY to
return this form to Student Conduct in Thompson Hall’s Office of Residential Life/Learning Communities by the deadline
indicated above. You must complete a refection paper of your experience and turn this in at the same time. Failure to
comply with this sanction as outlined on this form may result in additional charges being filed against you.
I have read the above instructions and agree to comply with them.
Student’s Signature: _________________________________________ Date: _______________________________
TO BE COMPLETED BY SITE SUPERVISOR:
I, ___________________________________, verify that the above student has completed a total of __________ hours
with our site.
Site Supervisor’s Signature: __________________________________________ Date: _________________________
HOURS WORKED
DATE
IN
OUT
#HOURS
DATE
IN
OUT
#HOURS
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CIVIC ENGAGEMENT TIME SHEET (State University of New York College at Brockport)

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Completed 27 August 2020

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