BISHOP MOORE CATHOLIC HIGH SCHOOL
COMMUNITY SERVICE VERIFICATION FORM
3901 Edgewater Drive Orlando, FL 32804 www.bishopmoore.org email@example.com
INCOMPLETE FORMS WILL BE RETURNED UNPROCESSED.
COMMUNITY SERVICE OFFICE USE ONLY
Date Received: __________________ Date Received: __________________
STUDENT NAME (PLEASE PRINT): (FULL NAME/NO NICKNAMES PLEASE)
SERVICE SITE INFORMATION - one form per service site
NOTE: All students must fulfill their community service requirement at a NON-PROFIT organization NAME OF ORGANIZATION: NAME/POSITION OF CONTACT PERSON FOR ORGANIZATION : CONTACT PHONE NUMBER:
DESCRIBE IN DETAIL THE SERVICE YOU PERFORMED: _________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
SERVICE LOG - specific dates & times are required
(to be completed by the contact person for the organization at the time service is performed)
DATE OF SERVICE
TIME OF SERVICE
# OF HOURS SERVED THIS DATE
SUPERVISED THIS DATE BY
(PRINT NAME & INITIAL here for every work shift)
DO NOT SIGN A BLANK FORM! You may be contacted to verify SUPERVISOR MAY NOT BE RELATED TO STUDENT.
TOTAL NUMBER OF HOURS LISTED ABOVE: ___________
By my initials, I verify that the above named student completed the community service hours listed.
DO NOT SUBMIT THIS FORM WITHOUT ALL SIGNATURES
I submit the above Community Service Hours to fulfill my requirement for the current school year. I UNDERSTAND THAT ANY MISREPRESENTATION ON THIS DOCUMENT WILL RESULT IN A REFERRAL TO THE DEAN OF STUDENTS FOR DISCIPLINARY ACTION. Student Signature: _______________________________________________________________________ Date: _______________________ By my signature, I verify that my son/daughter completed the community service hours at the non-profit...
Please join StudyMode to read the full document