AISN Community Service Approval Request

Purpose: Through community service students are given opportunities to become responsible citizens by helping others while learning selflessness and fostering personal growth.

STUDENT INFORMATION

Last Name:

First Name:	Graduating Year:

ORGANIZATION INFORMATION

Name of Organization:	Department:

Name of Supervisor:	Phone Number:

E-Mail Address:

Description of service to be performed:

Dates of service

Beginning:	Ending:

Student/Parent

I verify that I am willing to provide the service described above. I understand that I must fully complete all parts of the Community Service Verification Form including the reflection page in order to have my completed service hours processed to fulfill my community service graduation requirement of 10 hours for this school year.

Student’s Signature	Place and Date

By signing below, I verify that I have given approval for my child to participate in this service activity, and that he/she has completed the hours of service as indicated above.

Parent’s/Guardian’s Last Name	Parent’s/Guardian’s First Name

Parent’s/Guardian’s Signature	Place and Date

Community Service Coordinator Approval

I have reviewed the application above and I approve this service for up to

hours of community service credit.

Coordinator Last Name	Coordinator First Name

Coordinator’s Signature	Place and Date