Last Dollar Grant Service Hours Form

2009-2010 SERVICE HOURS FORM STUDENT MUST COMPLETE (Please Print Clearly)

Student’s Name: __________________________________________________________ Social Security Number: _________________________ College ID #: ___________________ Home Address: ______________________________________________________________ Zip Code: _________________ Home Telephone Number: ___________________________ Name of College Attending: ____________________________________________________ **************************************************************************************** Please use the following volunteer activity to fulfill my Service Hours requirement for my 2009-2010 Last Dollar Grant: 1) Name of Agency/Program for Whom Hours Were Donated: __________________________________________________________________________ 2) Address: _________________________________________________________________ 3) Telephone Number: ________________________________________________________ 4) Date Activity Was Completed: ________________________________________________ 5) Description of Your Participation: __________________________________________________________________________ **************************************************************************************** To be given credit for your service hours, this form must be signed by both you and by a representative of the program for which you volunteered. This is to certify that the above student did volunteer a minimum of four hours in the way described above. Agency Representative Signature: ________________________________________________

Title: _______________________________________________________________________ Mail to: I KNOW I CAN, 3798 E. Broad St., Columbus, OH 43213 or fax to (614) 233-9512 by June 11, 2010.