HSA Community Service Reporting Form
Complete all the information below to submit your community service hours for verification and posting to your student record. If you have questions or problems, please contact Karen Moroney at karen.moroney@polk-fl.net
First Name *
Your answer
Last Name *
Your answer
Student ID Number (last 6 digits only) *
Your answer
Graduating Year *
Your answer
Harrison Department *
Your answer
Student Email *
Your answer
Agency Name *
Your answer
Activity Performed *
Your answer
Date (or Dates) Hours were Earned (mm/dd/yy) *
Your answer
Total number of Hours Earned (max 8 hours per day) *
Your answer
Name of Person who can verify your hours *
Your answer
Email address or phone number for verification purposes *
Your answer
Submit
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