Semester of Service Passport Completion Recognition You may need to enable Macros and ActiveX controls to adequately access this form 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