Student Name: ________________________________________________________ StarID: ______________________________________________
Service Agency: _______________________________________________________ Phone: ______________________________________________
Supervisor: _________________________________________________________________________________________________________________
Duties Performed: ___________________________________________________________________________________________________________
Date Time in # Of Hours Supervisor’s Signature
Total Hours Worked: _____________
Supervisor Comments/Feedback:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
_________________________________________________________
Student’s Signature Date
_________________________________________________________
Supervisor’s Signature Date
Students need to submit this form, along with the Reflection Paper (no less than 60 days prior to graduation) as attachments in the Assignment
Submission folder within NCTC’s service learning course in BrightSpace (D2L).
Service Verification Form
To learn more about Service Learning visit
northlandcollege.edu/servicelearning
Student
SERVICE LEARNING INITIATIVE
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signature
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click to sign
signature
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