Community Service Report Form


Complete this form at the end of your community service.   Type the information or write legibly.

Student Name:   ______________________________________

Site Information:

Name:   _____________________________________________

Address:  ____________________________________________

City: _________________________________

Phone Number:   _________________________________

Name of Supervisor:  _________________________________

Date of Service:  __________________________________

Name of Activity:  _________________________________________

No. of Hours:   _________________________

Verification Signature:  _____________________________________

Write a clear and full description of your personal participation in this community service activity:

  • Provide a summary of your responsibilities, duties, tasks, etc.
  • Reflect on the benefits that you consider the activity was, or may be, to others.    What did you take away from the experience?
  • Identify improvements that could be made.

Student Signature:  _________________________________

Date:  _________________________


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