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ILLINOIS VALLEY COMMUNITY COLLEGE

CO-CURRICULAR TRANSCRIPT PROGRAM

ACTIVITY VERIFICATION FORM

 

Studentís Name _________________________________________________________

 

Studentís 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 Representativeís Name ____________________________________________

 

Activity Representativeís Title/Position ______________________________________

 

Activity Representativeís Phone Number ____________________________________

 

Signature of Activity Representative ______________________________ Date _____