Fullerton College
Student Service Learning Record
Official Timesheet

Semester:         Fall                   Spring                        Year: ________

Course:                                                                                                Instructor:                    

Student Name:                                                                                      Phone:             _______

Address:                                                                                                                                                          

City:                                                                                                     State:                Zip Code:                    

Perm #:                                               

Service Organization/Agency:                                                                                                               

Address:                                                                                                                                                          

City:                                                                                                     State:                Zip Code:                    

Phone: (   ____)                                                    

Agency Supervisor:                                                                                                                                          

Special Requirements:                                                                                                                          

                                                                                                                                                                       

STUDENT SERVICE RESPONSIBILITIES (what you did):                                  _________________

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

STUDENT LEARNING OBJECTIVES (why you did it):                                                                           

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

SERVICE RECORD:          

Dates                  Hours               Dates                Hours                Dates               Hours

           
           
           
           
           

Total Hours:                                                              

Student Signature:                                                                     Date:                    

Supervisor Signature:                                                                Date: