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Pathway Community Service Tracking Form 2016-2017
Please provide complete information. The Pathway Progam will verify your completed community service hours with the person/organization listed below.
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
EMPL ID#
*
Your answer
EMAIL
*
Only provide NOVA student emails (
email.vccs.edu
)
Your answer
Your Primary Campus
*
AN
AL
WO
MA
LO
Other:
Required
Name of Community Service Event or Agency
*
Your answer
Date of Community Service
*
Your answer
Hours Worked this Event
*
(entry should only be numbers, ie. 8. Do not include text ie. 8 hours)
Your answer
Community Service Supervisor or Contact Name
*
Your answer
Contact Persons Number
*
Your answer
Contact Persons email
*
Your answer
Summary of your experience
*
Responsibilities, tasks, etc.
Your answer
. Overall, how satisfied were you with your community service experience?
*
1 - strongly dissatisfied
2 -
3
4
5 - strongly satisfied
What did you like about your community service experience?
*
Your answer
. What would you change about the community service experience?
*
Your answer
Should all students be REQUIRED or ENCOURAGED to participate in service?
*
REQUIRED
ENCOURAGED
Other:
Did you develop a really good relationship with someone as a result of your community service experience?
*
(check all that apply)
My supervisor at the community service site
Another student working at the same site
A person I was helping
No one
Other:
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