40 Hour Community Involvement Form Page 2
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1
2NAME OF SCHOOL
40 HOUR COMMUNITY INVOLVEMENT FORM
Completion of Community Involvement Activities
Please record your volunteer activities below, once an activity has been completed. When 40 volunteer hours have be
completed, submit this form to Student Services.
STUDENT NAME: __________________________________________
Activity
# of Hours
Date of
Organization Name,
Supervisor’s Name and
Completion
Address and Telephone #
Signature
TOTAL
FOR OFFICE USE ONLY...
Completion has been noted on Student’s OST.
STUDENT
SIGNATURE: ___________________________________ DATE: _____________
________________________________________________
Signature of School Official
Date
PARENT
SIGNATURE : ___________________________________ DATE: ______________
** Photocopy this page for your records**
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