Community Service Form

COMMUNITY SERVICE FORM
Student Information
Student Name*

First NameLast Name
Grade*
Organizational Name*
Supervisor Name*

First NameLast Name
Phone Number of Organization*
Supervisor Email Address*
example@example.com
Pre-approval required if not an organization.
Services Information
Date of Service*

MonthDayYear
Date
Number of Hours Completed*

:HourMinutes
Time Worked*
Work Performed*
Please select your response
Was this student cooperative?*

YesMostlyNo
Were they enthusiastic and pleasant?*

YesMostlyNo
How would you rate the quality of this student's service?*

GoodFairPoor
Would you like to have this student’s help again?*

YesNo
Supervisor Signature*

Clear
Legacy Christian Academy

27680 Dickason Drive
Valencia, CA 91355
Phone: 661.257.7377
Should be Empty:

COMMUNITY SERVICE FORM