Student's First Name:   

Student's Last Name:  

Office/Department/Room #: 

Volunteer Period #1:     Volunteer Period #2: 

Supervisor's Name:   

Month:  SEPTEMBER  

Enter the number of periods  you have volunteered  in each box.  Place an "A:" in the box if you did not volunteer.  For example:  1 or 2 or A.

 Total the number of volunteered class periods: 

I will have this total verified by your office/teacher supervisor.

Print out the confirmation sheet which will appear after you submit this form.  This will be your record of hours.

Thank you, Ms. Gubing, F101, x2977