Student Name: ________________________________________________________ StarID: ______________________________________________
Service Agency: _______________________________________________________ Phone: ______________________________________________
Duties Performed: ___________________________________________________________________________________________________________
Supporting Documentation:
Letter from Agency
Certification/Award Received
Volunteer Roster
Other: _______________________________________________________
Total Hours Worked: _____________
_______________________________________________
Student’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
(Alternative Past Experience)
click to sign
signature
click to edit
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