Community Service Verification Form printable pdf download

Stevenson High School Community Service Verification Form

(a separate form must be completed for each activity, excluding GIVE activities)

The following form should be completed by the student and signed by the individual verifying

the activity.

I hereby certify that _________________________________________ has participated in the

Name

community service activity described below on __________________________________________

Date(s) (mm/yy)

for a total of _______ hours.

_________________________________________________________________

Name and title of person verifying activity

For verification purposes:______________________ ___________________________________

Phone Number

Email Address (optional)

Signature of person verifying activity: _______________________ (signature indicates approval)

Organization: __________________________________________________________________

Description of community service performed:

I verify these hours meet the following definition of community service: Volunteer service beyond

the confines of a traditional classroom that fosters civic responsibility for the benefit of the

community. This service is non-paid, non-graded, non-punitive and occurs outside the school day.

Student Signature: _________________________________ Date: _____________

Parent Signature: __________________________________ Date: _____________

Please Note:

• Submitting this verification sheet to the Community Service Coordinator does NOT guarantee the

hours indicated will automatically be applied to the total for the student.

• Please review all guidelines pertaining to the acceptable community service hours and verify any

questions with the Community Service Coordinator or see Community Service Webpage.

• It is the student’s responsibility to submit verification of hours along with the application the last

day of school before spring break of the year graduating.

.................................................................................................................................................................

For Office Use Only

Hours accepted: ___________________________________ Date: _____________

Community Service Coordinator Signature

Community Service Verification Form

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