Please keep a copy for yourself.

BUHS COMMUNITY SERVICE REPORT FORM

STUDENT SECTION

(Every item must be filled out completely in order for the form to be valid)

Work done during the summer due by September 30th, during the school year due June 1st

Name: ___________________________________________________Year of Graduation________________

Describe volunteer work performed:____________________________________________________________

_________________________________________________________________________________________

Number of hours volunteered:____________       Date(s) of volunteer work:_____________________________

(Document hours and dates worked on back of this form)

Student Signature:_______________________________________        Date: __________________________

____________________________________________

RECIPIENT SECTION

(To be completed by the person you volunteered for)

I verify that the above named student performed volunteer service for me/my organization and did not receive compensation or other consideration for this work.

Signature_____________________________________________      Date_____________________________

Printed Name:___________________________________________  Telephone number__________________

Organization & Address

________________________________________________________________________________________

________________________________________________________________________________________

_______________________________________________________________

OFFICIAL USE ONLY SECTION

(To be completed by the Community Service Coordinator)

Approved:  ______Yes  ______No      If no, why not?______________________________________________

Community Service Coordinator Signature:____________________________________ Date:_____________ 

Jkiehle@wsesu.org                                                        James Kiehle  451-3488   BUHS 2017-18