ILLINOIS VALLEY COMMUNITY COLLEGE
CO-CURRICULAR TRANSCRIPT PROGRAM
ACTIVITY VERIFICATION FORM
Student’s Name _________________________________________________________
Student’s Phone Number _________________________________________________
Category of Event (See Reverse) Please circle one
Club/Organization Leadership Development Career Development
Campus Service Community Service Athletics/Recreation Other
Name of Event __________________________________________________________
Your Title/Position For Event ______________________________________________
Description Of Your Responsibilities ________________________________________
________________________________________________________________________
________________________________________________________________________
Date(s) Of Activity (Please include all dates)
________________________________________________________________________
Total Number Of Hours Of Participation ____________
Activity Representative Verification Information
Activity Representative’s Name ____________________________________________
Activity Representative’s Title/Position ______________________________________
Activity Representative’s Phone Number ____________________________________
Signature of Activity Representative ______________________________ Date _____