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 Mr. Renz at daniel.renz@polk-fl.net
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First Name *
Last Name *
Student ID Number (full 10 digits) *
Graduating Year *
Harrison Department *
Student Email *
Agency Name *
Activity Performed *
Date (or Dates) Hours were Earned (mm/dd/yy) *
Total number of Hours Earned (max 8 hours per day) *
Name of Person who can verify your hours *
Email address or phone number for verification purposes *
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