Community Service Extracurricular Activity Form
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1Community Service/Extra Curricular Activity Form
Community Service is an action, performance, a “hands on” activity by an
individual without compensation or academic credit, whose effort will directly
benefit others. Participation or membership in an extra-curricular club or
organization does not constitute community service (i.e., meetings or rehearsals)
Student Name
CM
Total Hours Being
Student ID#
Date
Room #
Reported
(Last Name, First Name- Please Print)
Name of Organization
Date(s) of Service
# of Hours
Email
Name of Supervisor
Phone Number
(First & Last Name- Please Print)
(if available)
Supervisor’s Signature
Please describe your community service: what was your activity, where was it done, how did it benefit someone else
Name of Organization
Date(s) of Service
# of Hours
Email
Name of Supervisor
Phone Number
(First & Last Name- Please Print)
(if available)
Supervisor’s Signature
Please describe your community service: what was your activity, where was it done, how did it benefit someone else
Please keep a copy for your records
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