2011 – 2012 Service Learning/Community Service Form (See instructions below if you need help with this form. See the Policies and Guidelines for more information.)

All SL/CS hours must be done with a non-profit/charitable** organization and be documented. 1. Circle the year you GRADUATE:

2012

2013

2014

2015

2. PRINT Student Name: ________________________________________ ID#: ___________________ 3. Student email: _______________________________Activity: ___________________________________ 4. Location: ____________________________________ Date(s): ________________________________ 5. Your SRHS Class to which you are relating your activity: _______________________________________ 6. PRINT Name of Class Instructor: __________________ Instructor Sign: _________________________ School/Student background check completed for volunteering in other BSD schools: ________________

For Office Use Only: SL Hours _________ CS Hours _________ Signature: ______________ DOCUMENTATION BOX (“Doc Box”) You may use this box or attach your alternate documentation (details on back) to this form.

Must be filled out completely by event/activity official. Incomplete documentation will not be accepted. This student participated in the (event) ___________________________________________________________________ with (organization name) ___________________________________________on (dates) _________________________ at (location)______________________________ for a total of _______ hrs (log req’d if over 8 hours*). Print documenting person’s name: _________________________Documenter’s Title: ______________________________ Documenter’s contact info (e-mail or phone for verification): __________________________________________________ Documenter’s signature (no parent/relative/guardian): ________________________________________________________

MAKE and KEEP a copy of all documents for your records!

Attach:  Log (if over 8 hours*)

Student Signature: __________________________________

 Written reflection in essay form (for SL); No reflection, hours entered as CS

Date: ____________________________________________ (Academic Integrity Policy also applies to SL and CS hours.)

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Form Instructions and Information Line 1: Please circle the year you graduate. Line 2: Print LEGIBLY your name(s), including your legal name and the name you are called by and your ID #. Line 3: Print LEGIBLY the event or activity you plan to participate in. Line 4: Print LEGIBLY the location where you plan to participate, and the date or date range of the activity. Line 5: Print LEGIBLY which past or present (not future) course to which you are relating your experience. Line 6: Print LEGIBLY the name of the instructor of the course in Line 6, and have that instructor sign. Documentation Box: This is to be completed by an event/activity official only, not a parent, relative or guardian. Attach your log if over 8 hours. Attach your written reflection. Questions are on the back for your convenience. Make and keep a copy of all your documents. There is no school resource for this. Sign, date and turn in to the SL office. Hours expire after one year. Revised 10/2011 AF

Important Information See the Service Learning Information and Guidelines for complete Service Learning information.

Important Information: Please Read Seniors who do not finish SL on time will not be allowed to participate in graduation activities, including Senior Assembly or walking with the graduating class at Chiles Center. For SL credit, projects must be: 1) uncompensated 2) for a non-profit/charitable** organization, 3) linked to SRHS curriculum and 4) documented. SL/CS credit cannot be awarded for hours served to a student’s own family, private individuals, or for-profit businesses. Hours worked at for-profit businesses are not acceptable for SL credit, but may qualify for an internship through the College/Career Center. *For student safety purposes, no more than 8 SL hours will be allowed per day. **Charitable is defined as non-profit organizations, hospitals, or SL-approved facilities. See SL office if in doubt about approval. School/Student background checks . . . Students working with middle, elementary or disabled students must get approval from the SL office before working with these students. Failure to do so will result in loss of SL/CS hours.

Written Reflection Instructions (must be in essay form): Reflection Instructions and Prompts: (Reflection required for SL, not for CS). These prompts are meant to help you, but not limit you. Feel free to add details about your experience that you consider important. 1. 2. 3. 4. 5.

What specific tasks did you do in your project/event/activity? How did your efforts benefit the community/school/organization? What did you learn/teach while doing the above that is related to your Southridge curriculum? What did you learn about yourself and/or others while doing this project? Would you do this or something similar to this again? Why or why not?

FAQ’s The 30 Hour Cap – Explained: The number of hours allowed per project is unlimited. However, the first 30 per activity type (sports, religious activities, fundraising, performance, library, etc.) will count as Service Learning, and any beyond that will be Community Service. Students have been known to serve hundreds of hours at a single activity, but because it is a goal of the Service Learning program for students to have diverse experiences that connect to as many of their classes as possible, the number of Service Learning hours that can be earned in any type of activity is limited to 30. All hours, both SL and CS, count toward the goal of 200+ hours award (SL hours and CS hours are added together to reach the 200+ goal.), and will reflect well on a resume or application for work, college or scholarship. What counts as documentation? There are FOUR ways to get it (but you only have to have ONE): 1) the ‘Doc Box’ on the front of this page, 2) the ‘Doc Slip’ that is hanging in a pocket outside the SL office, 3) at the bottom of your log if over 8 hours, or 4) a letter from the organization that contains all the necessary information. No parent/relative/guardian signatures are accepted. Why do I have to keep a log? There are two reasons for the log: 1) to be sure we’re maintaining a safety standard for students and 2) frequently, when logs are turned in, it is discovered that students actually cheat themselves out of hours. For example: one student turned in 200 hours. When the log appeared to have errors, we reviewed it together and found that it was actually almost double what she had credited herself. We found a miscalculation in the hours that increased her total and also found that she had left things off because she thought they didn’t count, when they actually did. This is the case in most of the errors found in logs.