Date rcvd __________ Initials _________

Verification of Community Service

Baruch Scholars and Provost Scholars
Instructions: Submit this completed form and reflection question responses to your Honors advisor no later than May 1 for
each service activity.
Student information:
Last Name: _____________________ First Name: ____________________ Soc Sec No: X X X - XX - __ __ __ __
Semester/Year of Entry into the Program: ___________ Phone ___________________________________
Baruch Email: ________________________________________
Service Information:
Name of organization: ___________________________ Address: ______________________________________
Description of service: _________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Dates of Service:

Number of Hours Worked:

____________________

______________________

____________________

______________________

____________________

______________________

Total Hours:

______________________

Supervisor Signature: Your signature verifies the service activities, the number of hours completed, and that there was no
compensation for the service.
Supervisor/Agent Name: __________________________________ Title: _________________________________
Telephone number / e-mail address: _______________________________________________________________
Signature: ___________________________________________________ Date: _____/______/_____
Advisor Approval: ____________________________________________

Date: _____/______/_____

Reflection Questions: (Please type your response)

1.

What did you learn about yourself?

The following prompts may help you respond to this question: Was there an instance when you had to move beyond your
comfort zone? Did this experience challenge assumptions and/or stereotypes you may have had? How did you relate to the
population served? What did you learn about the people around you (population served, staff, fellow volunteers, etc.)?

2.

What is the mission of the organization and how does it connect to the larger political, economic, social, and cultural
forces that shape American society? Can you think of any alternative solutions for addressing the needs this organization
serves?

3. Explain whether you would engage in this community service again. How has this experience influenced how you will
engage in your next service project?