Name:       	Submission Date:       	
Job Title:       	
Work Assignment / Location:       	
Home Address:       	
City:       	State:       	Zip:       	
Educator ID:       	Project Name:       	

Date	Hours	Description of Activity	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
TOTAL