DUBOIS AREA SCHOOL DISTRICT ‘Senor Hh Schoo! ‘COMMUNITY SERVICE FORK studenttame Ye stun Ve rece Grade _\e Home Phone Number 'L> “12 le student cel Phone Number_R1. 2 BS Porentvardion SC ve Vamvecos ¢ Pwenforsncat Pontes a ACLS nor SUS eS 73 eek Asenerfste equened ren “SCout Agency Contact Person resac, Katee ir phone 233-0 Te Siro of agency Conver 22 = ate 9-50-15 Students: Upon filing of your community service hours, please have the ageney ‘supervisor complete the bottom portion ofthis form and return it alone witha brief Paragraph reflecting your community servic experience to Mrs. MeCleary, DAKS, room 128 or the Main office. J Hisst Lome Coy has completed _‘2_ hours of community service Tens Suis “ey (egsovor C wucu (Bathe helped with the following Projets: Se. reer Supervisors Signature bate “AHS Authorization ate : ta the Failure to listed ste pre-approves ‘completed hours,DUBOIS AREA SCHOOL DISTRICT Senior High Schoot COMMUNITY SERVICE FORM. student nome_aSersha Cen Grade _4 tome Phone Number. Student cellphone Number LWT U-2ZGQP Foren uarin Parent/Guardian Call Phone Numbers Agency/ite Requested Cra vowennnn Marg ae Bie wks Signature of Ageney Contac Dtaaeler Me Cette pare _LefufF ‘Students: Upon fling of your community service hours, please have the agency Supervisor complete the bottom portion ofthis form and return it along witha bret Paragraph reflecting your community service experience to Mrs, McCleary, DAKS, room, 128 or the Main office, n hes completed “5 hours of community service at He/she heiped with the following ma Ee nee teed oe Cee adteog/a {Pas auoroon ate m Is needed itie this fo jam fa ohavea nore stenrcantousdmay seule