National Junior Honor Society 2015-2016 VOLUNTEER SERVICE HOURS VERIFICATION SHEET & SERVICE INFORMATION FORM NAME: _______________________________________________________________________ HOMEROOM TEACHER: _______________________ CIRCLE QUARTER:

1st

2nd

3rd

ROOM NUMBER: _____________

4th

NAME OF ORGANIZATION FOR WHICH YOU WORKED: __________________________ ______________________________________________________________________________ ______________________________________________________________________________ DATE YOU WORKED: ____________ TIMES YOU WORKED: ______________________ NUMBER OF HOURS YOU WORKED: ________________ BRIEFLY EXPLAIN WHAT YOU DID WHILE WORKING: ___________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PRINTED NAME OF ADULT WHO SUPERVISED YOU: ______________________________________________________________________________ SIGNATURE OF ADULT WHO SUPERVISED YOU: ______________________________________________________________________________

SUPERVISOR PHONE NUMBER: ________________________________________________ Check one:

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Current Member: Return this form to Mrs. Gerbitz room 108. Service hours due dates: End of each grading Quarter First Quarter: Friday October 9, 2015 10 service hours are due by end of second quarter: December 18, 2015 15 service hours are due by end of third quarter: March 11, 2016 Fourth Quarter: Friday April 22, 2016