DUBOIS AREA SCHOOL DISTRICT Senior High School 425 rea avenoe Plone: 81471-8101 me BA Ys 700 fe gta 3 commut VICE FORM Pre-Approval student Nome GOSS Coowee rade SN" ome Phone Huber (1218-04) Sent el Phone Numbers8) e022 S59 rrentiGuatdon SOIR ¥ ION Coosa Cel Phone Numbers (ZA) OZAOSS © (Bt) wOB= Vw So PfBiy Coho u¢ prone 27-9927 cate finn 2-12 | DANS Authorization _ Date. Pavent/Guare Agency/Site Requested Agency Contact Person signature of Agency Contact “Students: Upon Tufling of your community service hours, please have the agency ‘supervisor complete te bottom portion of this form and return it along with a biet ‘aragrap aflecting your community service experience to Mis. McCleary, DAHS, 1oom Cage boat erconpeted_5” tous communty sree Lite ed aan ee ed elon projects: Derders PothCiels Fhe bn bes 7 superiors Sgatue €, vue B20