Semester of Service Passport Completion Recognition
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Please type your information in the expanding text boxes and fully complete both forms
Award Certificate Order Form
Name:
Mr.
Ms.
First:
Last:
Address:
City, State, Zip Code:
Contact Information:
Email:
Phone:
Name of Institution:
Total Service Hours:
Hours Served During:
Fall
Spring
Year:
Please print your name exactly as you want it to appear on your certificate:
Please select your award recognition level:
Community Contributor (45-69 service hours)
Community Changer (70-99 service hours)
Community Catalyst (100+ service hours)
By selecting this box I agree to allow Missouri Campus Compact to post my name and information on their website.
Yes, I would like my name and information included with a Letter of Recognition to the President of my institution.
Would you like additional persons to receive a letter acknowledging your accomplishment?
If so, please enter the information below for one or two persons. Letters with an international address will be
enclosed with your award packet to be forwarded by you to that person.
Ms.
Mr.
Dr.
Ms.
Mr.
Dr.
Organization:
Organization:
Street Address 1
Street Address 1
Street Address 2
Street Address 2
City, State, Zip
City, State, Zip
Congratulations on your outstanding achievement!
Please mail your completed passport and assessment page with a copy of this request.
We will not issue a certificate until your passport is received and validated.
Missouri Campus Compact, Missouri State University
901 S. National Avenue, Springfield, MO 65897
Phone (417) 836-3104
Fax (417) 836-3105
Revised 7/2014
Assessment of Learning Outcomes (required)
Please respond to the following and include these pages with your passport and certificate request
Name:
Institution:
Semester:
Assessment of Learning Outcomes through your Semester of Service Passport
As a result of the engagement activities listed in my passport…
Strongly
Disagree
Somewhat
Disagree
Agree and
Disagree
Equally
Somewhat
Agree
Strongly
Agree
I have developed a stronger sense of belonging in
the community
I have a better understanding of social issues in
the community
I have a better understanding of the needs and
resources in the community
I have clarified my own strengths and
weaknesses
I have connected what I am learning in my
courses to everyday life
I will continue to serve my community in the
future
Revised 7/2014
Please use the space below to write a letter to a family member or friend telling them about your engagement
experience. This is only for assessment purposes and will not actually be mailed. There is no required length
for the letter.
Tell them (1) about your experience(s), (2) what you learned about the community/others, (3) what you
learned about yourself, (4) any challenges you faced, and (5) how these experiences impacted your views of
civic engagement and/or continued service.
Revised 7/2014