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Student Name Principal
Mr. P. Adam
School Name Telephone Number
Bishop Smith Catholic High School 735-5496
Please provide the information requested below about the community involvement activities in which you plan to participate.
Estimated Estimated
Name of Charity, Parish, Community Service Club, etc. Location of Activity and Supervisor’s Name Signature of Approval
Number Date of
and Description of Activity Phone No. (Please Print) (Principal, Counsellor)
Of Hours Completion

***Is each activity identified on the school board’s list of approved activities?  Yes  No

If you checked “No”, you must obtain written approval from the principal (the principal’s signature above) before starting the activity.

Student’s Signature Date Parent’s or Guardian’s Signature Date

In accordance with the Municipal Freedom of Information and Protection of
Privacy Act, all personal information collected under the authority of the
Education Act is intended to be used to determine eligibility for selection
and participation in the Community Involvement Activities Program, which is
required for an Ontario Secondary School Diploma.