Community Service Log

COMMUNITY   S ERVICE   L OG  

 

 

Name:     _______________________________________________    

Citation   N umber:     _ __________________________________    

 

 

 

 

Date   o f  

Location   o f  

Time   I n  

Time   O ut     Total   T ime  

Supervisor’s   N ame   Supervisor’s  

Program  

Service  

Service  

(in   h ours)  

Signature  

Contact  

Number  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I,   _ _____________________________________________   ( name),   d eclare   u nder   p enalty   o f   p erjury   t hat   I   c ompleted   a t   l east   8   h ours   o f  

community   s ervice   a s   d ocumented   a bove   a nd   r equired   b y   t he   d iversionary   p rogram.    

 

 

  _______________________________________________________    

(signature)