W,{LTERS STATE COMMTNITY COLLEGE

OFFICE OF BEHA\IORAL AND SOCIAL SCIENCES

\.OLUNTEER HOURS \'ERIFICATION AND
FIIIAL STUDENT EVALUATION
Student Volunteers: \\'hen 1 ou have completed your hours, take this form to the agency superuisor at
your sen ice learnine site, Once )our supervisor has verified your hours, make sure he/she completes the
rest of the torm and mails it to the address below.

Agencl Sr.rpen'isor: The sfudent's grade is dependent upon the timely completion and submission of this

fom.

Piease cLrmplete and retum to:

Darlene Smith
Walters State Communify College
Behavioral/Social Sciences Division
500 South Dary Crockett Pkwy
Morristown, TN 37813{89,

-:*lent \ame:

*t
supervisor'sName:

[t, tsa rt Dr.u'i..

phoneNumber:

I ce*ify that the above named sdnt vohmteered at our ageney for a total

of

Ar
,:1,

hours this

sL-mester.
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-.

Dependability

ABCDfApplicable
/

Attpndance

Ccoperation
Interpersonal Skills

WorkEthic
Concern forNeeds of Community and Clients

Client Response to Sedent

Agency Respoase to Student
Overall Evaluation of Performance

Not