UCLA HEALTH SCIENCES VOLUNTEER OFFICE HOURS OF

Revised 1/28/2020

UCLA HEALTH SCIENCES VOLUNTEER OFFICE

HOURS OF VERIFICATION AND AWARD REQUEST

Please note, UCLA Health Sciences Volunteer Office will only verify service hours and/or issue a certificate

once the minimum commitment of 100 SERVICE HOURS has been met.

Please submit to your specified coordinator and allow 2-3 weeks for processing:

Clinical UCLA Health Sciences: CRV@mednet.ucla.edu

Non-Clinical UCLA Health Sciences: NCV@mednet.ucla.edu

CONTACT INFORMATION

Full Legal Name:

Full U.S. Address:

City: State: Zip Code:

Phone Number: Email:

AUTHORIZATION

I hereby authorize UCLA Health Volunteer Services to release my hours/certificate to:

Please check one:  Self  Other, please complete Contact Information:

Full Name: Relation:

Full U.S. Address:

City: State: Zip Code:

Please indicate which program you are part of (check all that apply):

 Clinical UCLA Health Sciences (formally Direct Referral)  Non-Clinical UCLA Health Sciences (formally DGSOM)

Please indicate which documentation to request:

 Verification of Hours (Print-Out of Recorded Hours)  Certificate of Completion

Delivery Method:

 Mail (Certificate and/or Verification)  Email (PDF of Verification only to Self)

NOTE: Please RETURN your ID Badge to the Volunteer Office in order to request a Certificate of Completion.

If you are not within the area, you can mail it to:

UCLA Health Sciences Volunteer Office

757 Westwood Plaza, Suite B791

Los Angeles, CA 90095

Attn: Lily Zhang

Signature Date