Community Service Validation Form

5 hours = certificate 10 hours = Bronze 20 hours = Silver 30 hours = Gold 50+ hours = Platinum

USE INK ONLY

STUDENT NAME ________________________________________________________ GRADE LEVEL _______

ADVISOR _____________________ School Year _______________

Agency/Organizatio Type of Service Total Start End Print name of Person Phone # of Signature of
n Hours Date Date Responsible Person Person
Responsible Responsible

Thank you for serving your community with CHARACTER, COURAGE, AND COMMITMENT! #wareagleway
#CHSserves #CharacterCourageCommitment
*Please return completed forms to your advisor.