First Name: Last Name: ctcLink ID:
Community Service/Volunteer Hours
Up to three (3) points will be awarded to applicants who have documented hours of community service/volunteer
experience. Please use this Community Service/Volunteer Hours Form to document your experience.
● 1-9 hours = 1 point ● 10-19 hours = 2 points ● 20 or more hours = 3 points
The purpose of this point is to encourage applicants to gain experience working with diverse, often underrepresented
populations within the community. The intent is for applicants to gain insights about community needs and resources, as
well as communication skills needed in the healthcare field.
Sample of approved experiences:
Special Olympics involvement
After-school youth programs
Community aid through
church services
Volunteer with school nurse in
health-related activities
Outreach programs or health
related missions
The primary goal is to demonstrate community service and activity.
Your hours cannot include observation hours or any hours that were compensated in anyway.
Volunteer Experience Organization/Agency:
Volunteer Role/Job Title:
Volunteer Coordinator/Supervisor Name: Email:
Volunteer Coordinator/Supervisor Signature:
Volunteer Coordinator/Supervisor Phone Number: Date:
Log of Volunteer Experience Hours (may attach additional page if needed):
Please Describe Activities Involved
I attest that all information in this form is accurate.
Applicant Signature: Date:
Volunteer experience must five (5) years current from expected program entrance.
Anything beyond five years will not be considered for points in selection.
Applicants may submit multiple forms to demonstrate total hours accumulated. Use one form per organization/agency.
Updated 11/2020
Clark College Dental Hygiene
Program Community
Service/Volunteer Hours Form
