Community Service Verification Form
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3Community Service Verification Form
Student Name: _________________________WWW Group Leader: _________________________
NO
grades can be
Group Leader’s PreApproval Signature: ___________________________
given for service,
Parent/Guardian Permission: I, parent/guardian of the abovenamed student, give my permission for my
neither lowered,
son/daughter to participate in the community service activity described below.
raised, nor extra
credit, except by
Parent/Guardian Signature: _____________________________Date: _________
WWoW leaders
Dates When the AboveDescribed Community Service Occurred and Validating Signature:
for routine
verification of
1. Date: _______Time: _______ # of Hours: ______
quarterly service.
Organization: __________________________________________________________
NO
Supervisor’s Signature & Position: ________________________________________
pay may be
received for
Phone Number or Email Address: _________________________________________
service.
NO
2. Date: _______Time: _______ # of Hours: ______
credit will be
given for service
Organization: __________________________________________________________
during a student’s
Supervisor’s Signature & Position: ________________________________________
regular school
hours.
Phone Number or Email Address: _________________________________________
NO
credit will be
3. Date: _______Time: _______ # of Hours: ______
given for
extracurricular
Organization: __________________________________________________________
activities or for
student aide
Supervisor’s Signature & Position: ________________________________________
activities.
Phone Number or Email Address: _________________________________________
NO
credit will be
given for
4. Date: _______Time: _______ # of Hours: ______
community
Organization: __________________________________________________________
service
conducted for
Supervisor’s Signature & Position: ________________________________________
activities related
to the ICS
Phone Number or Email Address: _________________________________________
communityie….c
arnival, sports
5. Date: _______Time: _______ # of Hours: ______
programs, ECAs,
etc.
Organization: __________________________________________________________
Supervisor’s Signature & Position: ________________________________________
Phone Number or Email Address: _________________________________________
NO
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