Student Community Service Assignment Form 2018-2019
Tier 2 and 3 Community Service Hour(s) Assigned. Please remember to contact parent and administration about this community service assignment. Students will be reminded every other Friday about hours owed.
*** Make sure you conference with student regarding assigning them community service. Students need to be told you are assigning them community service and why. ***
Student Last Name
Student First Name
Staff Name (filling out this form)
Choose the behavior(s) that warranted this community service assignment.
Behaviors that disrupt learning (1 hour) (repeated behaviors, not first offense)
Disrespectful towards adult or peers (1 hour)
Taking or Abusing Property (1 hour)
Disciplinary Removal from Class (1 hour)
Play fighting, wrestling (1 hour) (not resolved by teacher warning)
Cheating/Plagiarism (2 hours)
ADMIN ONLY: Physical Fighting
ADMIN ONLY: Substance Related Incident
ADMIN ONLY: Harassment/Bullying
ADMIN ONLY: Possession and/or use of weapons
ADMIN ONLY: Fireworks, setting fires, vandalism/graffiti or other damages to campus
Total Service Hours Assigned
Please add up the assigned hours from above.
Has the student's parent been contacted? (This is a required task. Please compete within 24 hours of assigning service.)
No, I am in the process
No, I need translation assistance
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