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Community Service Time Sheet
Student name: ____________________________________________________________________________________
Student email: _____________________________ Student Phone: _____________________________
Hours required: _________ Date assigned: ______________ Date to be completed by: ______________
Brief description of community service program (to be completed by the student):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I hereby certify that the hours recorded are complete and accurately reflect my hours worked.
Student signature: ___________________________________________________________
Agency Information
Agency name: _____________________________ Agency contact name: _____________________________
Agency address: _____________________________ Agency Phone: _____________________________
I hereby verify that the above SUNY Poly student has completed a total of ______ hours with this agency.
Supervisor name: _____________________________ Supervisor signature: _____________________________
Campus Life Office Use Only:
Received on: ___________________________ Case Number: _________________________
Signature of completion & verification of hours: _____________________________________________________
