Name of Page______________________ Name of class/service _________________________

Date that activity occurred___________ Date submitted______________

SCA Name of teacher (if class) or person in charge _______________________

Mundane name of teacher or person in charge __________________________

Area of class (circle one) Arts/Sciences Service Chivalry

Number of hours that activity took _______________________________________________

Level of page(s) (can be multiple, but please indicate) _____________________________________

Below, please describe a brief description of the activity. If class or A/S activity, describe (briefly) what you learned from this (this includes martial activities, but not necessarily service):





















For Dean School Staff use: Date received ________ Date Approved ____________

Approved by (initials)_______________________ If not approved, please list reason for rejection:



Form created 1/03