West Islip High School Community Service Verification Form

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WI
WEST ISLIP HIGH SCHOOL
COMMUNITY SERVICE VERIFICATION FORM
Date: _______________________
Graduation Year __________________
Current Grade ____________________
This form verifies that______________________________________, a student at West Islip High School
Name of Student (please print)
has been participating in Community Service with _________________________________________, and
(Name of Organization)
has completed _________________ hours, between __________________ and _________________.
(# of hours)
(date began)
(date ended)
______________________________
_________________________________
Name of Supervisor (please print)
Phone Number
_____________________________
_________________________________
Signature of Supervisor
Signature of Student
Student:
List activity you were involved in during Community Service:
________________________________________________________________________
________________________________________________________________________
National Honor Society Endorsement – If this activity qualifies for National Honor Society hours, the signature of the West
Islip NHS Advisor must certify this:
___________________________________
_______________________________
NHS Advisor Signature
Date
International Baccalaureate Community Action Service Endorsement – If this activity qualifies for IBCAS hours, the
signature of the West Islip IBCAS Advisor must certify this:
___________________________________
_______________________________
IBCAS Advisor Signature
Date
Students: Once you have completed this form and obtained all necessary signatures, bring
this form to the Counseling Office for final approval
Counselor Signature: _____________________________________ Date: ___________________________
Entered by (initials) _________ Date: _____________________________
(rev.1/11 ark)

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