Student Name:

Email Address:

Student/Cultural Org:

Type of Activity:
Weekly Service w/regular participants (complete only once per semester for each group)
Group Name:

One-time service event
One-time service event title

Educational event or speaker
Educational event/speaker title

Training event
Training event title

Date: All Semester (weekly) January February March April May June July August September October November December    -select date- Fall semester Spring semester 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    2005 2006 2007 2008 2009

Day of week: Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Start Time:   AM PM     End Time:   AM PM

Number in Group/Attendance: 

If this event included volunteer service, please list the students' names.

If located at a community organization, please complete the following:

List location if on campus or other:


Did the Civic Engagement Center assist in scheduling this activity?
Yes No
If no, which office or student group scheduled the event?

Event Summary/Recommendations (activity, transportation, publicity, suggestions for future, etc)

Committee Members and their responsibilities (if applicable)

Orientation & Reflection Process (if applicable)

Expenses (supplies, honorarium, refreshments, transportation, etc.)

I am from a student/cultural org and would like to discuss possibilities for collaboration with the Civic Engagement Center.

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