Student Service Learning Activity Verification Form
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1Office of Special Education and Student Services
STUDENT SERVICE LEARNING
MONTGOMERY COUNTY PUBLIC SCHOOLS
ACTIVITY VERIFICATION
Rockville, Maryland 20850
STUDENT INSTRUCTIONS: Complete this form legibly in blue or black ink. Submit it to the school student service learning (SSL) coordinator
by the following deadlines:
Service completed during the summer — DEADLINE: Last Friday in September.
Service completed during 1st semester — DEADLINE: First Friday in January.
Service completed during 2nd semester — DEADLINE: First Friday in June.
STUDENT INFORMATION—To be completed by the student prior to review from the nonprofit tax-exempt organization.
Name
Last
First
MI
ID Number
Parent/Guardian
Phone: Home
Work
School
Grade
First Period Teacher
Student e-mail address
Student Reflection: Think about your service-learning activity. Respond to the following questions in a written paragraph below.
• What did you do?
• What need did your service address?
• Who benefitted from your service?
• What did you learn about yourself?
• How was this experience connected to something you learned in a class at school? (For example, English, Mathematics,
Science, Social Studies, Arts, Physical Education, Health, Foreign Language, etc.)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
NONPROFIT TAX-EXEMPT ORGANIZATION INFORMATION—To be completed by the supervisor after the phases of
preparation and action have occurred, and the student reflection paragraph has been read and approved.
Organization __________________________Federal Employer Identification # __ __- __ __ __ __ __ __ __ Phone ___________________
Address _______________________________________________________________ ____________________________________________
Street
City
State
ZIP Code
e-mail
Describe Activity (performed) ___________________________________________________________________________________________
Service Record
# Hours Per Day
Total # Hours Completed
# Days
Date From
Date To
(8 in a 24 hour
(award 1 SSL hour for
of Service
period maximum)
every hour of service)
Supervisor
Print Name
Title
____/____/_____
Signature, Supervisor
Date
SSL COORDINATOR USE ONLY
□
Check if automatic hours are attached to this activity as a result of course instruction.
Verification form submitted to coordinator ____/____/_____
Date
Date ____/____/_____
Hours earned previously
+ Hours for this activity
= Total hours including activity
MCPS Form 560-51, June 2015
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