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Confirmation of Community Service Form
Please note that there is to be only one community service project per form.
I,
in accordance with the
Jack and Jill of America Foundation’s scholarship eligibility requirements, verify that I performed the following community
ser- vice project. (*See description for “active” community service):
Name of Organization
Address
City, State, Zip Code
Name of Project
Briefly describe the service project/duties:
Hours of Service Performed
Signature of Supervisor
Supervisor’s Title
Telephone Number
Student Social Security Number
Student Name (Print)
Student Signature & Date
This form certifies that the above named project was performed within the time frame outlined in the scholarship application.