Silver Service Application 2021-2022
Directions: Complete one application for each club or organization for which you serve. For Example, complete one for a school club's service activities, one for volunteer work at an animal shelter, and another for all the service you will do at church this year.

THESE ACTIVITIES MUST BE PRE-APPROVED. THEN YOU WILL RECEIVE A TIMECARD. RETURN THIS FORM TO YOUR SCHOOLS' SERVICE LEARNING COACH.
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STUDENT NAME (FIRST AND LAST) *
MPS STUDENT I D # *
FULL ADDRESS *
PARENTS' NAME and PHONE NUMBER *
Service Learning Coach MAY call for parent verification
JUNIOR HIGH SCHOOL *
E-MAIL *
NAME OF ORGANIZATION *
CITY *
ORGANIZATION CONTACT PHONE OR EMAIL *
NAME OF SUPERVISOR *
Who will you be helping? *
What service will you be performing to help those people, animals, or places? (Use verbs) *
How will these people, animals, or places benefit from your help? *
What are three or more skills you will learn through your service? (example: leadership, problem solving, organize a project, speak in public, teamwork, research an issue) *
Service Learning Participation Terms and Rules *
By reading and checking the following boxes, I agree to the terms and rules of Service Learning as listed below. If I do not complete these items my hours will not be counted toward the Silver Service Award.
Required
Contact with Adults
I acknowledge that some activities of the Cooperative Education/Internship Program occur off school property and involve adults who are not employees of Mesa Public Schools. I acknowledge and accept that my son/daughter may be instructed by or work with a person whose work experience and background have not been investigated by Mesa Public Schools.
Parent/Guardian Signature *
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