Name of Organization    Date

Place/Type of Community Service     

Date of Service      Times 

Individual Responsible for Service: Name           

                                                          Phone      

                                                          E-mail   

Signature of Site Facilitator 

NPHC President Approval 

NPHC Advisor Approval 

This form must be picked up prior to the community service and turned into the NPHC Office within 24 hours of the service project.

PLEASE REMEMBER:  No food can be passed out on the ASU campus without the permission of Sodexho.  This includes ice cream socials, etc.