Clio High School

Student Community Service Form

Name: ____________________________________________ Student ID #: ___________________

Grade: __________ Number of Service Hours: ___________ Date Performed: ___________

Project Description:
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Hours performed during the summer months MUST be turned in no later than the end of the first
marking period of the school year. Hours earned during the school year MUST be turned in no
later than one week from the date of completion.
* 5 hours are due by March 16, 2018 and additional 5 hours will be completed on April 11, 2018!
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Name of Non-Profit Organization: ________________________________________________________

Contact Person to Verify: ______________________________ Phone #: _______________________

(May NOT be a relative)

NOTE: No credit for community service will be given until verification has been completed.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ OFFICE USE ONLY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date Service Recorded: _________________________ Recorded By: _________________________

Hours Entered into PowerSchool: _________________