Senior Project Community Service Verification Form

Completed forms must be given to the mentor and will be provided to the review panel.

Student’s Name:_____________________________________________________________________________

Mentor’s Name:______________________________________________________________________________

Organization’s Name:_________________________________________________________________________

Supervisor’s Name:___________________________________________________________________________

Supervisor’s Contact Number:___________________________________________________________________

Supervisor’s E-mail:___________________________________________________________________________

Date Hours Description of Work/Progress

Total hours served: ___________

By signing below, all parties attest that the above information verifying the student’s participation is true and
accurate.

___________________________________________ ___________________________________________
Student’s Signature/Date Supervisor’s Signature/Date