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Community Service Verification Form

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10 views

Community Service Verification Form

Uploaded by

britneysparkles123
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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NO

grades can be given for


service; neither lowered,
COMMUNITY SERVICE VERIFICATION FORM raised, or as extra credit.
All Community Service Must Be Unpaid and Volunteer Work
For details please refer to SUHSD Community Service Guidelines NO
pay may be received for
service.
Student Name: __________________________________________________ ID #: __________________
NO
School Name:_____________________________ Social Science Teacher:_________________________ family members may be the
recipients or supervisors of
service.
1. To be completed BEFORE performance of the community service activity:
NO
Description of Community Service: credit will be given for
service during student’s
Name of Organization: __________________________________________________________________ regular school hours.

NO
Describe the Community Service Activity: __________________________________________ credit will be given for
extracurricular (co-
_______________________________________________________________________ curricular) activities or
student aide activities.
_______________________________________________________________________ NO
credit for service will be
Parent/Guardian Permission: I, parent/guardian of the above-named student, give my permission recorded without a parent
for my son/daughter to participate in the community service activity described below. or guardian’s signature.

NO
Parent/Guardian Signature: ____________________________________________Date:_______________
credit will be given for
work with a profit-making
Social Science Teacher Pre-Approval. If you complete hours without teacher pre-approval, you take the organization.
risk that your teacher may not accept your service hours as valid.
NO
Social Science Teacher Signature: __________________________________________Date:___________ credit will be given for
court-required or other
punitive service.
2. To be completed DURING performance of the community service activity:

Date Time From ___to ___ # of Hours Supervisor Signature Position Phone #

Total Number of Hours: ___________ For additional hours use Verification Log –Attachment A.

Sweetwater Union High School District programs and activities shall be free from discrimination based on gender, sex, race, color, religion,
ancestry, national origin, ethnic group identification, marital or parental status, physical or mental disability, sexual orientation or the
perception of one or more of such characteristics. SUHSD Board Policy 0410.

Revised Form - May 2013.


Examples of Possible Community Service Activities:

 Assisting at Boys or Girls Clubs  Working with Habitat for Humanity


 School sponsored tutoring  Helping with beautification or clean-up programs
 Helping at a hospital, convalescent home, or orphanage  Helping a non-profit organization such as St. Vincent de
 Assisting with City Parks & Recreation Programs Paul, Salvation Army, or Goodwill etc.
 Helping with sports events of younger children  Giving blood (2 hours credit each time blood is given)
 Helping with a non-profit community sports team  Working with a political campaign
 Helping at a Key Club or community event  Working as an unpaid poll worker on Election Day
 Helping at activities sponsored by a religious institution  Working with community theater

3. To be completed AFTER performance of the community service activity:

Write a “reflection” on your community service involvement that addresses the following ideas:
 Explain the purpose or mission statement of the organization you served.
 How did your work benefit the community?
 Reflect on how this affected you personally, including how you felt about the service and yourself.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Student Signature: _____________________________________________________________Date:_____________________

4. To be signed AFTER the student has completed all the requirements of this form:
Parent/Guardian Validation: I, the parent/guardian of the above-named student, certify that my son/daughter performed the
described community service at the times listed above.

Parent/Guardian Signature: ________________________________________________________Date:___________________

Social Science Teacher’s Signature as Verification that the hours are accepted and submitted to the school records:

Teacher’s Signature: _____________________________________________________________Date:___________________

Student should have two copies of this form: one for the teacher and one to keep in the student’s personal records.

Revised Form - May 2013.

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