West Islip High School Community Service Verification Form printable pdf download

West Islip High School Community Service Verification Form

WEST ISLIP HIGH SCHOOL

COMMUNITY SERVICE VERIFICATION FORM

Date: _______________________

Graduation Year __________________

Current Grade ____________________

This form verifies that______________________________________, a student at West Islip High School

Name of Student (please print)

has been participating in Community Service with _________________________________________, and

(Name of Organization)

has completed _________________ hours, between __________________ and _________________.

(# of hours)

(date began)

(date ended)

______________________________

_________________________________

Name of Supervisor (please print)

Phone Number

_____________________________

_________________________________

Signature of Supervisor

Signature of Student

Student:

List activity you were involved in during Community Service:

________________________________________________________________________

National Honor Society Endorsement – If this activity qualifies for National Honor Society hours, the signature of the West

Islip NHS Advisor must certify this:

___________________________________

_______________________________

NHS Advisor Signature

Date

International Baccalaureate Community Action Service Endorsement – If this activity qualifies for IBCAS hours, the

signature of the West Islip IBCAS Advisor must certify this:

___________________________________

_______________________________

IBCAS Advisor Signature

Date

Students: Once you have completed this form and obtained all necessary signatures, bring

this form to the Counseling Office for final approval

Counselor Signature: _____________________________________ Date: ___________________________

Entered by (initials) _________ Date: _____________________________

(rev.1/11 ark)

West Islip High School Community Service Verification Form