Free community service form 40Free community service form 40
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Heritage High

Midlothian Independent
School District 4000 FM 1387 ~
Midlothian, TX 76065
972-775-6509 ~ 972-775-7841/Fax

Community Service Form
To Be Completed by STUDENT’S FAMILY
Student _____________________________________ ID# __________ Class of ________ Date: _____________
Last, First
Home Address ______________________________________________________ City ____________ ZIP________
Home Phone ____________________________ Parent e-mail ___________________________________________
Service cannot be done for pay or any kind of reward and should be in an activity that is helping others (non family
members). We, the person signing below, have reviewed the information on the back side of this form, and in signing
we verify and confirm the activity(ies) performed were legitimate.
Student Signature_________________________________ Parent Signature_______________________________

-------------------------------------To Be Completed by SERVICE PROVIDER
Organizations Name ____________