Middle Tennessee State University
Sport Clubs
Community Service Verification Form
Club: ______________________________________________
Date of Community Service:_____________________
Location:_____________________________________
Community Service Provided:______________________________________________________________________
Number of Club Members in attendance: _____________
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Hours provided: ____________________
Name (Please PRINT legibly)
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I certify that the above list and hours worked is valid.
Club Officer Signature: ___________________________________
Office Position: ______________________
I certify that the above information is accurate to the best of my knowledge.
Service Program Administrator Signature: ________________________________________________________
Position: ______________________________________
Date: _________________________________________