Service-Learning Reflection Form
To be completed by adult site supervisor
Dates of service:
Students, parents, and individuals/organizations who accept student
____/____/____ to ____/____/____
service volunteers should note Guideline #1 (found on the reverse side)
PRIOR to service activity.
PLEASE PRINT OR TYPE
Signature of Adult Project Supervisor
Reflection to be completed by student: (If you need additional space please attach a separate sheet) Now that you
have completed your service-learning project you are ready to write a description of your activity. Tell why you chose to
do this project. What were your responsibilities and what did you actually do? How did your actions make you feel and
how do you think the community benefitted from your actions? Would you select this project again?
This completed form must be returned to the school Service-learning Coordinator
within one year from the time the service is complete.
Confirmation/Approval of Service-Learning Hours
Upon approval of your service-learning activity, this section will be returned to you for your records.
Please complete the following:
Student Name:____________________________________Homeroom Teacher:__________________
(To be completed by the school-based Service-Learning Coordinator )
Dates of Service:________________
Signature: Service-Learning Coordinator_________________________________Date:_____________