Community Service Verification Form
Student Name
First Name
Last Name
ID Number
Grade
School Name
Advisor Name
First Name
Last Name
Description of Community Service Activity
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Name of the Organization
Description of Community Service Work
Explain the purpose (mission statement) of the organization you served
How did (or will) your work benefit the community?
Community Service Days & Hours
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Community Service: Please Fill Out Accordingly
Permission
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I, undersigned, agree with the following statement
I, parent/guardian of the above-named student, gave my permission for my son/daughter to participate in the community service activity described above.
I, the parent/guardian of the above named student, certify that my son/daughter performed the described community service at the times listed above.
Parent/Guardian Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
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Print
Submit
Should be Empty: