WVU School of Dentistry

Community Service Information Form

Total Hours: (Preparation & Presentation)
Total Hours Travel: (To and From)
Total Hours Worked:
Name:
Service Date:
Agency Name: (School, Nursing Home, etc.)
County and Town Where Program was Presented:
Agency Supervisor and Phone Number:
Number of People Encountered at the Program: (If school include grade level)
Type of Program: (Dental Health, Tobacco Awareness, etc.)
Description of Program: (Use back of this form if needed)

*Each individual student is required to submit a Project Protocol. Do not assume since a partner or other member(s) of a group have submitted a Project Protocol that you are exempt. Failure to submit an individual Project Protocol will affect your first-semester grade.