Civic Engagement Report Form
**If your civic engagement program is scheduled after the report deadline, please submit a form outlining your plans for the program.**
Club Name *
Please do not abbreviate or use an acronym.
Your answer
Club President *
(or primary student contact)
Your answer
Email Address *
(for student contact)
Your answer
Club Advisor *
Your answer
Civic Engagement Project Name *
Your answer
Civic Engagement Project Location *
Your answer
Civic Engagement Project Contact *
Please list the name and phone number or email address of your community contact for this service project.
Your answer
Date(s) of Program *
(MM/DD/YYYY)
Your answer
Description of Program *
Your answer
Who participated in this program and for how long? *
Please add the full names and hours of participation for ALL students who attended the civic engagement program (to the best of your knowledge):
Your answer
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