Student Community Service Verification Form
This form is used to verify and document student community service hours. Students should complete this form with their service organization supervisor and submit it for academic credit or record-keeping purposes.
Student Full Name
*
School Name
*
Grade Level
*
Choose One
9th Grade
10th Grade
11th Grade
12th Grade
Service Organization Name
*
Organization Contact Person
*
Contact Phone
*
Service Start Date
*
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Service End Date
*
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Total Hours Completed
*
Description of Service Activities
*
Provide a detailed description of your community service work
Skills Learned and Personal Growth
*
Reflect on what you learned from this experience
Supervisor Evaluation of Performance
*
A
Excellent - Exceeded expectations
B
Good - Met all expectations
C
Satisfactory - Met most expectations
D
Needs Improvement
Impact Statement
*
Explain how your service made a difference
Organization Supervisor Signature
*
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Type
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Date Submitted
*
/
/
Your form has been saved. You can complete it using this link within %(day)s days.
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