Community Service Form - Burleson High School

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Forms must be turned in no later than 30 days after event.
If the event is in the summer, it must be turned in no later than 30 days after school starts!
Class of ____________
Burleson High School
100 Elk Drive
Burleson, TX 76028
(817) 245-0000
COMMUNITY SERVICE VERIFICATION FORM
Please put only one Community Service Activity on a form
Name: ________________________________________________________________________
Last
First
Middle
Student ID Number: _____________ Grade: ____________ Hours worked: ____________
Name of the community organization:
Description of work:
Actual date work was performed:
Community Service codes: (Check the code that applies to the activity listed below.)
CH - _____ Church (includes Mission Trips, VBS, Nursery, etc.)
CM - _____ Community Ministries (includes food/clothing/homeless projects)
CV - _____ Civic duties (includes City, Chamber, civic clubs, public Library, Honeyfest, etc.)
ED - _____ Educational (includes school activities, library, etc.)
MD -_____ Medical (includes hospital, nursing homes, etc.)
SP - _____ Sports (coaching, sporting events, concession stand, etc.)
Check the School Organization you are earning hours for:
_____ Key Club
_____ National Honor Society Circle one - Group Hours or Individual Hours – FOR NHS ONLY
_____ ROTC
_____ Other (specify Organization) _____________________________________________
Signature of Adult Supervisor
Date
Printed name of Adult Supervisor
Organization
Phone Number of Adult Supervisor
Signature of Student
Date
Committee Decision
______ Approved
______ Not Approved
________________________________
Signature of Committee Member

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