MERRITT ACADEMY
Community Service Learning Agreement

Student's Name _________________________________________    Grade __________

Organization/Project: _________________________________________     Phone: ____________________________

Organization's Supervisor: __________________________________________

Responsibilities: __________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Expected starting date: _______________    Expected date of completion: __________________

TO BE COMPLETED BY STUDENT

I, _____________________________________, agree to abide by the regulations and policies of this organization and to perform to the best of my ability, the tasks specified in this agreement. I agree to call the organization in advance if I am detained or plan to be absent for any reason. Failure to do so will result in dismissal from this organization and hours served to that date will be forfeited.

________________________________________________ (Student's Signature)

TO BE COMPLETED BY PARENT/GUARDIAN

I, _____________________________________, the parent or legal guardian of ____________________________________ (student), agree to support and encourage my son/daughter in the community service she/he will perform for the agency listed above. I accept responsibility for transportation to and from the organization recognizing the school has provided service opportunities within the community.
Please check one:
I understand that my son/daughter may be photographed or video recorded during this assignment.
____  I give my permission for his/her picture to appear in the school publications or the local media.
____  I DO NOT give my permission for his/her picture to appear in school publications or the local media.

________________________________________________ (Parent/Guardian's Signature)

TO BE COMPLETED BY ORGANIZATION

_______________________________________ (Name of Organization), agrees to accept the responsibility of supervision, evaluation, meaningful educational experience for this student in exchange for the community service.
Hours volunteered: _________

_________________________________________________ (Signature of Organization's Representative)

FOR COMMUNITY SERVICE LEARNING OFFICE USE ONLY

_________________________________________________ (Principal's Pre-Approval)

_________________________________________________ (Principal's Signature)

_____________ Hours Credited
_____________ Date Returned
_____________ Graduation Year