Community Service Verification Form

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Stevenson High School Community Service Verification Form
(a separate form must be completed for each activity, excluding GIVE activities)
The following form should be completed by the student and signed by the individual verifying
the activity.
I hereby certify that _________________________________________ has participated in the
Name
community service activity described below on __________________________________________
Date(s) (mm/yy)
for a total of _______ hours.
_________________________________________________________________
Name and title of person verifying activity
For verification purposes:______________________ ___________________________________
Phone Number
Email Address (optional)
Signature of person verifying activity: _______________________ (signature indicates approval)
Organization: __________________________________________________________________
Description of community service performed:
I verify these hours meet the following definition of community service: Volunteer service beyond
the confines of a traditional classroom that fosters civic responsibility for the benefit of the
community. This service is non-paid, non-graded, non-punitive and occurs outside the school day.
Student Signature: _________________________________ Date: _____________
Parent Signature: __________________________________ Date: _____________
Please Note:
• Submitting this verification sheet to the Community Service Coordinator does NOT guarantee the
hours indicated will automatically be applied to the total for the student.
• Please review all guidelines pertaining to the acceptable community service hours and verify any
questions with the Community Service Coordinator or see Community Service Webpage.
• It is the student’s responsibility to submit verification of hours along with the application the last
day of school before spring break of the year graduating.
.................................................................................................................................................................
For Office Use Only
Hours accepted: ___________________________________ Date: _____________
Community Service Coordinator Signature

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