Center for Civic Engagement
Bristol Community College
Leadership Record
Semester ______________
No later than the 11
th
week of class, send this completed record to for your pre-approved leadership project
the Civic Engagement Coordinator in L117 at the Fall River Campus.
PLEASE PRINT
Course Information (if project is course-related; otherwise, skip this section):
Course ID (ex. SOC 101)
Section (ex: A01)
CRN (ex. 14338)
S-L Professor
E-Mail
Student Information:
Student Name (Last, First, MI)
Address (Street, City, State, Zip)
Student ID
E-Mail
Cell Phone
Home Phone
Community Partner Information:
Organization
Address (Street, City, State, Zip)
Supervisor’s Name
Supervisor’s Title
Phone
E-Mail
Leadership Project Information:
Project Description:
Dates of Service (From)
Dates of Service (To)
How many individuals did you
serve with your project?
How many individuals did you
lead on your project?
Of those you led, how many
were BCC students?
Of those you led, how many
were not BCC students?
Total Number of Your Hours
Total Number of Hours for Your Entire Team
Mutual Understanding:
The undersigned agree that the information included in this contract is accurate and that the above listed service was performed by the
student completing this application. The student has verified that all BCC students who have served at least 10 hours on this project have
submitted either a Service-Learning Contract or a Community Service Record with the Civic Engagement Office. The student leading a
project during the Spring semester must submit this record by April 15
th
in order to receive a red cord at the Civic Engagement Recognition
Breakfast and be publicly recognized at graduation that year.
AGREED BY:
BCC/COMMUNITY PARTNER SUPERVISOR
Signature Date
STUDENT LEADER
Signature Date
Bristol Community College • 777 Elsbree Street • Fall River, MA 02720 • 508-678-2811
click to sign
signature
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click to sign
signature
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