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