COMMUNITY SERVICE VERIFICATION FORM Date Submitted:__________________________ Student Name:___________________________ Student Graduation Year:_________________ This is to certify that ___________________________, a student at Pittsburg High School has completed _______ hours of community service hours (unpaid) to ______________________ (a non-profit organization agency). Dates the services occurred: ____________________________________________________. His/Her duties involved the following responsibilities: _________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My evaluation of the following qualities of this student’s services: Excellent Good Fair

Needs Improvement

Attitude

_____

_____

_____

_____

Punctuality

_____

_____

_____

_____

Assumes Responsibility

_____

_____

_____

_____

Performance

_____

_____

_____

_____

Organization/Agency name:____________________________________________________ Address: ___________________________________________________________________ (Street) (City) (State) Supervisor name:_____________________________________________________________ ____________________________________ ______________________________________ (Signature of Supervisor) (Position or Title of Supervisor) Supervisor’s telephone number for verification of hours:______________________________ Thank you for supporting Pittsburg High School community service. Jon Bishop Principal

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