Why I Am Me

Topics: Non-profit organization, University, Community service Pages: 2 (257 words) Published: August 25, 2013
BISHOP MOORE CATHOLIC HIGH SCHOOL

COMMUNITY SERVICE VERIFICATION FORM
3901 Edgewater Drive Orlando, FL 32804 www.bishopmoore.org cs@bishopmoore.org

INCOMPLETE FORMS WILL BE RETURNED UNPROCESSED.

COMMUNITY SERVICE OFFICE USE ONLY
Date Received: __________________ Date Received: __________________

STUDENT NAME (PLEASE PRINT): (FULL NAME/NO NICKNAMES PLEASE)

GRADE:

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
FROM TO

# 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.

information.

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...
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