Community Service Verification Form (Page 2 of 2) in pdf

Examples of Possible Community Service Activities:

Assisting at Boys or Girls Clubs

Working with Habitat for Humanity

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School sponsored tutoring

Helping with beautification or clean-up programs

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Helping at a hospital, convalescent home, or orphanage

Helping a non-profit organization such as St. Vincent de

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Assisting with City Parks & Recreation Programs

Paul, Salvation Army, or Goodwill etc.

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Helping with sports events of younger children

Giving blood (2 hours credit each time blood is given)

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Helping with a non-profit community sports team

Working with a political campaign

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Helping at a Key Club or community event

Working as an unpaid poll worker on Election Day

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Helping at activities sponsored by a religious institution

Working with community theater

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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.

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How did your work benefit the community?

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Reflect on how this affected you personally, including how you felt about the service and yourself.

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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.

Community Service Verification Form Page 2