Verification and Record Sheet – List of Completed Activities

Student: __________________________________________ _ Form Teacher: _____________________________________ Form: ___________

Please provide the information requested below about the community service activities in which you are/have been involved.
This sheet must be signed by your supervisor DURING your placement.

The completed form needs to be submitted in Canvas – Year 10 Students – Assignments by Friday 4 th November
School approval must have been granted before undertaking any activity.

Contact phone
Time and Duration
COMM NATURE OF LOCATION Date of activity number Supervisor’s Form Teacher’s
ORGANISATION e.g. 6pm–8.30pm
SERVICE ACTIVITY (suburb) DD/MM/YY and name of signature and date signature
2.5hrs
TIER Supervisor
Legacy - 9am - 12pm Mr. Blencowe
SCHOOL Fund raising Various 06/04/23 9826 0711
Australia 3 hours 06/04
 Total Community Service hours completed:______hours
Due date: September 15 2023

Student’s signature: _______________________________________ Date: __________________

Parent’s or Guardian’s signature: _______________________________________ Date: __________________