COMPLETE THIS FORM AND SUBMIT TO THE DESIGNATED PERSON AT
YOUR HIGH SCHOOL NO LATER THAN APRIL 30.
Hours must be volunteered and may not be in conjunction with any
school related activity or function. Providing false information will result
in the student’s disqualification from the Promise Program.
COMMUNITY SERVICE VERIFICATION FORM
Full Student Name (First, Middle, Last)
Student ID Number (High School)
SUPERVISOR’S AFFIRMATION: By signing below, I affirm that the student named on this form completed the specified number of community service hours on the date listed. I
also affirm that he/she did not receive any type of payment or reward for his/her act of service.
PHONE AND/OR EMAIL
By signing below, I affirm that the information provided on this form is true and accurate to the best of my knowledge. I also affirm that I did not receive any ty