Community Service Bursary Student/organization Service Agreement Form

Community Service Bursary

Student/Organization Service Agreement

THIS FORM MUST BE SUBMITTED BEFORE THE STUDENT BEGINS HIS/HER VOLUNTEER HOURS

STUDENT: (Please print)

I, ______________________________, a student in grade _______ as of September 20____ at__________________________________________,

(Student Name)

(High School Name)

accept the terms and condition of the Community Service Bursary Program.  The Department of Workforce and Advanced Learning shall not be

held liable for any accident or situation that might occur while I am a volunteer for the organization listed below.

Address______________________________________________ City ________________________ Prov _______ Postal Code _________________

Student Email _________________________________________________ Telephone _______________________ Graduation Year ____________

(Please print clearly)

Student Signature __________________________________________

Date _______________________________

ORGANIZATION:  (Please print)

_______________________________________________________, a non‐profit organization, accept the terms and conditions of the Community

(Organization Name)

 Service Bursary Program in accepting ____________________________________________, a student in grade _____ as of September 20____ at

 (Student Name)

_______________________________________________________, Department of Workforce and Advanced Learning shall not be held liable for

(High School Name)

any accident or situation that might occur while the student is a volunteer for this organization.

Address______________________________________________ City ________________________ Prov _______ Postal Code ________________

Organization Email _____________________________________________ Telephone _______________________ Fax ______________________

             

(Please print clearly)

Signature of Signing Authority _______________________________ Print Name ____________________________  Date_____________________

(The person who signs this form is responsible for supervising and logging the student’s volunteer hours and submitting their hours to the Community Service

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)

Bursary program by the September 30

 deadline.

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PLEASE NOTE: It is the student’s responsibility to ensure all the required records are submitted before September 30

of their graduation year to receive a bursary in November. This office will not be sending out reminders of missing

information.

FAX to (902) 368-6144 or Mail to Department of Workforce and Advanced Learning, Community Service

   

Bursary Program, Box 2000, 176 Great George Street, Suite 212, Charlottetown, PE C1A 4K9.

Personal information on this form is collected under subsection 32(2) of Prince Edward Island’s Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988, c. F‐15.01 and will be used for the

purpose of Application for Community Service Bursary.  If you have any questions about this collection of personal information, you may contact the Community Service Bursary Program, PO Box 2000, 

Charlottetown, PE C1A 7N8, (902) 368‐4640.