AISN Community Service Verification Form

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 performed:

VERIFYING INFORMATION

Date of Service:	Hours Served:	Initials Supervisor:

Date of Service:	Hours Served:	Initials Supervisor:

Date of Service:	Hours Served:	Initials Supervisor:

EVALUATION

Evaluation of student’s work:	Unsatisfactory	Satisfactory	Excellent

Comments:

Verified by Supervisor

Supervisor’s Signature	Place and Date

Student/Parent

I verify that I have completed the above documented service and have followed all guidelines. I understand that I must fully complete all parts of the form including the reflection page in order to have my completed service hours processed to fulfill my community service graduation requirement of 20 hours.

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

REFLECTION

Fill out the following questions as completely as possible, feel free to use additional sheets of paper if necessary.

Why did you choose this activity? Do you have an interest in this area?

What did you observe during your service learning activity that made an impact on you?

How was this activity similar or different from other educational activities?

What did you learn?

Was this a positive or negative experience for you and why?

How does this contribute to you being a responsible citizen?