Community Service Form


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_____________________
The purpose and type of community service or volunteer work will be completed at the
Date(s) of community service________________________________________________
Hours per week___________________________________________________________
Signatures Required:
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
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.


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