Your Name________________________________________Date__________Grade Level_____

Place of Service (Please put name of agency, street address, town and phone #)

________________________________________________________________________________________

________________________________________________________________________________________

Name of Service Supervisor________________________________________ Phone#____________________

Supervisor’sSignature_______________________________________________________________________

Supervisor’sComments______________________________________________________________________

****PLEASE LIST ADDITIONAL DATES AND HOURS ON THE BACK****

REFLECTION ON YOUR SERVICE EXPERIENCE
Directions: Complete the following questions neatly in essay form. Service hours will not be credited toward your service requirement if this is not done. You must fill out a separate service verification form for each service done. Use the backside of the paper if you need more space. Return to the Office of Mission & Ministry Office. Thank You.

Reflection Question: Describe your service learning experience. Explain how you think your actions affected yourself or others. How could you connect this service experience to your faith? Go to back of paper for additional room to write.

PLEASE LIST ANY ADDITIONAL DATES AND HOURS HERE. *PLEASE TOTAL YOUR HOURS. YOU MAY ALSO USE THIS AREA TO ADD TO YOUR REFLECTION ANSWER.

Additional Room for Reflection