High School Community Service Verification Form printable pdf download

Bellevue School District

High School Community Service Verification Form

Graduation Requirement = 40 hours

Students must earn forty (40) hours of Community Service as one of their graduation requirements. Students may begin

to earn these hours once they complete their eighth (8th) grade year. The hours may be earned all at one time, or in any

manner that meets the student’s schedule, during his/her high school years, but must be completed prior to the

student’s participation in a commencement ceremony and the granting of a diploma.

Student Information:

Name

Year of Graduation

___________________________________________________

____________

School __________________________________

Student ID #___________

Counselor _______________________________

Date Submitted _____________________

Community Service is any service that is done for non-profit agencies and organizations and/or religious organizations.

School service is also included. For activities that do not fall in these categories, justification is required to demonstrate

how the community is being served by the activities. For activities that occur over more than one day, a maximum of 10

hours/day is allowed for the 40 hours of community service required for graduation.

Community Service Contact Information:

Agency/Organization Name _________________________________________________

501(c)(3)ID#__________

Contact Person_____________________________________________

Title ______________________________

Email _____________________________________________________

Phone: (_______)___________________

Description of the Activities Completed: Describe the activities completed for Community Service, including how the

activity benefits members of the community and what you learned from this experience.

Dates of Service: From __________________________ To ___________________________

Verification: I hereby verify that the Community Service activities were completed as described above:

Agency Contact Signature(s): ___________________________________________________ Total Hours = ______

Parent/Student Confirmation of Hours of Service:

I hereby verify that the Community Service activities were completed as described above:

Student Signature:_______________________________________________

Parent Signature: _______________________________________________

School Acceptance:

_____I hereby accept the reported Community Service hours to satisfy the graduation requirement.

_____ I do not accept the reported hours because the activity does not constitute Community Service.

Administrator/Counselor Signature:

High School Community Service Verification Form