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Hazelwood School District
Community Service Form
STUDENTS: Please complete the entire form. Incomplete forms with inaccurate dates, lack of
signatures or dates of service will not be processed.
Student Name:

First

Class:

Last

Student ID#:

SERVICE INFORMATION
Name/Address of Organization:
_
Phone:

Email:

Website:

Description of Service:
Date(s) of Service:

Total Hours Completed:

Agency Supervisor Comments:

Agency Supervisor Signature:
Student Signature:
Community Service Coordinator:

Date:

(D/M/YY)

Parent Signature:
Date:

(D/M/YY)

Examples of acceptable Community Service activities include, but are not limited to:
Volunteering at a non-profit agency, church or hospital (Vacation Bible Schools, mission trips, church
picnics, church school/daycare)
Volunteering at a day care center that is listed as a 501(c)3 organization by the IRS.
Volunteering to manage high school sports teams, and assisting in theater and musical productions.
Creating a student led community service p