Eastern Florida State College • Center for Service-Learning and Civic Engagement
MULTIPLE PLACEMENT SITE
HOUR REPORT AND SHOAT VERIFICATION
Student Name: Student Number: Student Telephone
(Printed or typed)
Type of Activity: ❏ Field Study (4th & 5th Credit Option) ❏ Community Involvement ❏ Human Service Experience
❏ Service-Learning Class Option ❏ Volunteer Service ❏ Internship
❏ Student Organization/Club (Service Activity)
Organization and/or Event Name Organization Supervisor Name: Agency Telephone:
(Printed or typed)
Services Provided:
We (organization and student) certify that the following hours are correct.
Organization Supervisor Signature and Date:
Student Signature and Date:
Organization and/or Event Name Organization Supervisor Name: Agency Telephone:
(Printed or typed)
Services Provided:
We (organization and student) certify that the following hours are correct.
Organization Supervisor Signature and Date:
Student Signature and Date:
Organization and/or Event Name Organization Supervisor Name: Agency Telephone:
(Printed or typed)
Services Provided:
We (organization and student) certify that the following hours are correct.
Organization Supervisor Signature and Date:
Student Signature and Date:
Official Use Only: Date Received
________________
Verbal Verification Date
________________
Input by
________________
Dates or Time Frame:
Total Hours:
Dates or Time Frame:
Total Hours:
Dates or Time Frame:
Total Hours:
CS-009 Rev.02-14 DISTRIBUTION: White (Faculty Member) Yellow (Center for Service Learning and Civic Engagement) Pink (Student Copy)
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signature
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click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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