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Student Volunteer Program Verification Form

Cumberland County Schools (PINE FOREST HS)
Student Volunteer Program Verification form
Click here for the Printable .pdf form

Student Name:                                                                _____________            Student ID #                                    ___

Academic Year: 2018-2019           Grade Level:  SENIORS ONLY         Program Advisor:  Dawn Willis (Room 259)

Name of Organization:                                                                                                                                                              _    

Address:                                                                                                                                                                                             

Contact Person/Title:                                                                                                                                                                  _   

                                                                                                                                                                                                               

Date(s) of Service:                                                                                         ____               Total # of Hours:                              

Describe the nature of your community service:                                                                                                                       _ 

____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

I hereby acknowledge that all work described above has been satisfactory and fully completed.

No monetary compensation was paid to ____________________________________________________
                                                                                                                                (Print Name of Student)

 Contact person/service supervisor’s signature _______________________________________________

Confirming the amount of service conducted:                                                                                      Date:                               

Student’s signature verifying all information submitted is correct:
__________________________________________________                                                               Date:                        __  

Parent/Guardian signature:                                                                                                               _    Date:                                 

  • All documentation for community service hours must be posted on EDMODO and forms turned in within 30 days in order to be counted toward the Service Cord requirement.
  • You may not receive credit for the following activities: (1) anything that involves a class grade (2) anything that is politically connected (3) any activity that you receive monetary compensation for.
  • Class of 2019 = 50 hours
  • From 5/1/2018 – 4/15/2019
  • All hours must be logged in on GOOGLE CLASSROOM to receive credit.
    CODE: mbmqt16
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Published by Barbara Ratledge on August 22, 2018
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Cumberland County Schools
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910.678.2300

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