Community Service Hours Form
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1
2Community Service Hours
School Year 20________
Name: _______________________
Grade: ________
House: ________
Please use one form per service organization/opportunity for extracurricular service during the
20__________ academic year.
Once completed, please hand in this form to the Office of Youth Ministry and your reflection
st
assignment to your Theology Teacher by May 1
.
Name of Organization: __________________________________________________________________
Name & Title of Supervisor: ______________________________________________________________
Contact Number of Supervisor: ___________________________________________________________
Description of Service Performed: _________________________________________________________
_____________________________________________________________________________________
Date(s) of Service
# of Hours
Supervisor’s Initials
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I, ___________________________, have completed the stated hours at the stated organization printed
above, in coordination with my supervisor. I give my full permission for the student’s Theology teacher or the
Office of Youth Ministry to contact the agency to confirm my relationship with this organization.
_______________________________________
(Student’s Signature & Date)
_______________________________________
(Parent’s Signature & Date)
_______________________________________
(Supervisor’s Signature & Date)
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