Brescia University Serves Others--Individual report

Community Service Hours--Individual

Please complete this form for hours in any service project. One form for each of your service projects.

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* 1. What is your first name?

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* 2. What is your Last name?

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* 3. Status

1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

5th Year Student

Graduate School

Alumni

Faculty

Staff

Trustee

Other (please specify) or if Alumni, please state year of graduation.

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* 4. Place of Service

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* 5. Brief description of work.

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* 6. What was date of service?

Date

Date

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* 7. How much time (in hours) did you spend in service? (.5, 1.5, 2, 3.75, etc)

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* 8. If applicable, indicate Club, Organization, Sports Team, Class, etc with whom you were performing service.