Milpitas  High  School    

CONFIRMATION  OF  COMMUNITY  SERVICE  PLACEMENT  

 

______________________

_____________________

Student’s Last Name (please print)

___________

_____________

Student ID #

Graduation Year

Student’s First Name (please print)

_____________________ Phone Number

  will not need pre-approval, however in order to receive credit for Community Service You completed, it must adhere to these 4 pillars:  

• • • •

Community Service has a sense of purpose and meaning to the student Community Service is in service to others and the community Community Service promotes responsibility Community Service is recognized and valued

•

_________________ Community Service Agency Name

______________________ Community Service Agency Supervisor

_____________________________

___________

Address

City

______________ _____________________ FAX #

_______ Zip Code

_____________

Email Address

Phone Number

Brief description of service performed and how it adheres to the 4 Pillars (be specific):

      ____________________________________________________________________________________   ____________________________________________________________________________________   ____________________________________________________________________________________      

 

TO BE COMPLETED BY PARENT / GUARDIAN

My  child  has  my  permission  to  participate  in  this  Community  Service  Project.  

_____________________                    __________________________ Print Parent / Guardian Name

Guardian’s Signature

RETURN  TO  ROOM  P19  –  Ms.  Brown    -­‐    [email protected]                                                                                                                                                                              8/12/16    

                                          ___________

Milpitas  High  School   _____________

_____________________

_____________________________

_____________________

Graduation Year

COMMUNITY   SERVICE  STUDENT  TIME   CARD   Student ID # Phone Number

Student’s Last Name (please print) ____________________ Student ID #

Date

Student’s First Name (please print) _______________________ Phone Number

___________________ Graduation Year

*Attach a Confirmation Form for each agency listed below* Time In Time Out Hours Agency Name Agency Signature

TOTAL HOURS =

______

STUDENT SIGNATURE

____________________

To Calculate the Percentage of an Hour, Round Up or Down to the Nearest Quarter Hour.

15 Minutes = .25 / 30 Minutes = .50 / 45 Minutes = .75  

Important  Deadlines  for  Seniors:     • 20  Hours  Deadline:  First  Friday  in  April   • Maroon  Cord  Deadline:  Third  week  in  April   • Transcript  Deadline:  Second  Week  of  October     .  .  .  .    FOR  OFFICE  USE  ONLY  .  .  .  .  FOR  OFFICE  USE  ONLY  .  .  .  .    FOR OFFICE USE ONLY . . . . FOR OFFICE USE ONLY . . . . FOR  OFFICE  USE  ONLY   Hours Approved / School Site Coordinator’s Signature

_______________________________ - Ms. Brown \  

RETURN  TO  ROOM  P19  –  Ms.  Brown    -­‐    [email protected]                                                                                                                                                                              8/12/16