Student ___________________________________________________ (print clearly)     Grade _______

                 (last, first name)                                                                                 Year of graduation: ___________                                 

Total number of hours:  __________________

WESTERN HIGH SCHOOL

COMMUNITY SERVICE RECORD SHEET

·         Forms are due by the end of the school day on the last Friday in April—no late forms will be accepted (absolutely no exceptions). Forms handed in by the due date will be counted for that school year.

·         Community service hours done after the last Friday in April will count toward the next school year (make sure that the grade put in for summer hours is for the next school year).

·         Please place in the correct grade file in the front office.  It is helpful if you do not wait until the due date to hand in your form.

Award requirements:

30 hours per year (May through the end of April)—no extra hours carried over

1^st year: Certificate with Gold Seal

2^nd year: School Letter

3^rd year: Service Pin for Letter

4th year: Green Cord to be worn at Graduation

*******************************************************************

Service Agency/Location _____________________________________________

Date(s) ___________________________________________________________

What service did you provide?

How did serving others make you feel?

How did your volunteering change or help others?

_______________________________________________________________

Student signature                                                                                Date

________________________________________________________________________________

Authorized signature (where service was completed—non relative)                          Date