Community Service Form printable pdf download

Wesley Chapel High School

Community Service Form

Pre-Approval is Required*

Please note that community service is altruistic in nature, with the goal of benefiting the

community and its needs. Community service hours are to be completed outside of the student’s

regular school and work schedule and must be non-paid.

Please print clearly and fill in the blanks below:

Student________________________________________ ID # ____________________

Grade Level ____________________________________ Date____________________

Community Service placement will take place at:

Name of organization_____________________________City_____________________

Supervisor______________________________________Phone___________________

The purpose and type of community service or volunteer work will be completed at the

organization:_____________________________________________________________

________________________________________________________________________

Date(s) of community service________________________________________________

Hours per week___________________________________________________________

Signatures Required:

Student_________________________________________________________________

Parent/Guardian__________________________________________________________

Counselor/Career Specialist_________________________________________________

Supervisor @ organization__________________________________________________

The following agencies do not require pre-approval by the counselor:

Moffit Cancer Center

East Pasco Medical Center

James A. Haley VA Hospital

Have a Heart

Hospice

American Cancer Society

Red Cross

Meals on Wheels

Humane Society

Public Libraries

Big Brothers/Big Sisters

Churches – service benefiting the community and its needs

Interact/Rotary – in the community and after school hours**

Key Club/Kiwanis – in the community and after school hours**

National Honor Society – in the community and after school hours**

State Attorney’s Office/Teen Court**

** These hours must be pre-approved by the school sponsor of the club, Pasco Public Schools (examples-tutoring,

ABC projects, other projects directly benefiting students or the community).

After all information is complete, use the reverse side to log your service hours and attach documentation from each

agency. Return the completed documentation and log to your guidance counselor.

Community Service Form