Student Volunteer Service Application And Approval Form
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1STUDENT VOLUNTEER SERVICE
APPLICATION AND APPROVAL FORM
To be completed by student volunteer - PLEASE PRINT OR TYPE
Name: __________________________________________________
Student Number: __________________________________
Address: ____________________________________________________________________________________________________
Phone: __________________________________________________
Emergency Phone: ________________________________
Grade Level: _____________________________________________
Social Security Number: ____________________________
Usual Method of Transportation: _________________________________________________________________________________
Student Pledge: I agree to fulfill the duties and time commitments as listed in the agency job description including training sessions and
to provide adequate notice if I am unable to meet my commitments. I also agree to adhere to the roles and procedures of the agency at
which I am volunteering.
Student Signature: ________________________________________
Date: ____________________________________________
To be completed by agency volunteer coordinator/director or individual supervising the project - PLEASE PRINT OR TYPE
Name of Agency: _____________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Phone: __________________________________________________
Operating Hours: __________________________________
Contact Person: __________________________________________
Title/position: ________________________________________________________________________________________________
Days and hours scheduled for the student Volunteer: ________________________________________________________________
Brief description of the job(s) to be performed by the student: ________________________________________________________
____________________________________________________________________________________________________________
Certificate of Insurance on file: __________________________________________________________________________________
Contact Person Signature: __________________________________
Date: ____________________________________________
To be completed by parent/guardian - PLEASE PRINT OR TYPE
I give permission for _______________________________________________ to serve as a volunteer for the agency/project
indicated above on the stated days and for the stated hours.
I understand that he/she will be making a valuable and needed contribution to our community. I also understand that he/she will
not recieve monetary compensation for his/her services.
We have accident insurance with ______________________________________________ (name of insurance company) which will
cover my son/daughter/ward in the event injury of while engaging in this activity. I will assume responsibility for expenses incurred
as the result of any injury mu son/daughter might suffer while participating in this activity. If an change occurs in the policy, it is
my responsibility to notify the school’s principal or Student Volunteer Service Program coordinator.
Parent/Guardian Signature: _________________________________
Date: __________________________________________
To be completed by Student Volunteer Service Program Coordinator - PLEASE PRINT OR TYPE
For hours to be awarded in an attempt to meet the Service Learning Graduation Requirement or to earn a Silver Cord the Application
and Approval Form must be completed and submitted to the school’s Student Volunteer Service Program Coordinator. It is best if
this is done prior to starting the activity described in Part B.
Student Volunteer Service Program Coordinator Signature: ___________________________________________________________
Date Received:: ___________________________________________
Date Approved: ___________________________________
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