The Center for Service & Leadership reserves the right to verify any information presented on this form.

Tennessee Wesleyan College

SERVICE VERIFICATION FORM

This form must be submitted within 90 days of participation

to track your service activities.

TO BE FILLED OUT BY STUDENT:

Name: _____________________________________
Student ID #: _______________________________
Classification: Freshman

Sophomore

Junior

Senior

Major: _____________________________________

Are you graduating this semester?

Yes No

Was this service completed with a

Service-Learning course?

Yes No

Phone #: ______________
E-mail Address: ___________________@my.twcnet.edu
Project Date(s): ___ /___ /______ ___ /___ /______
Name of Organization Served: _______________________________________________________
Project Summary: _______________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

TO BE FILLED OUT BY SERVICE PROJECT SUPERVISOR

Name (Please Print): ________________________________ Phone #: ___________________
Email Address: ________________________________________________________________
Address: ____________________________________________________________________
TOTAL Number of Hours Student Served: _________
Supervisor Signature (upon completion): _________________________________________

OFFICE USE
Received: ___/___/___ By: __________
Approved: ___/___/____ By: ___________

Hours Earned: _____

PLEASE RETURN THIS FORM TO:

Service & Leadership at TWC, 204 E. College St., Athens, TN 37303

Phone: (423) 746-5231

Fax: (423) 744-9968