Community Service Learning Agreement
Student's Name _________________________________________ Grade __________
Organization/Project: _________________________________________ Phone: ____________________________
Organization's Supervisor: __________________________________________
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