Silver Service Application 2019-2020
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.
Email address *
STUDENT NAME *
Your answer
MPS STUDENT I D # *
Your answer
FULL ADDRESS *
Your answer
PARENT/GUARDIAN NAME *
Your answer
PARENT PHONE NUMBER *
Service Learning coach may call to for verification.
Your answer
JUNIOR HIGH SCHOOL *
Your answer
PARENT E-MAIL *
For parent communication with the service learning coach
Your answer
STUDENT E-MAIL *
Your answer
STUDENT CELL PHONE
If you have one and don't mind sharing so that the service learning coach may send you announcements
Your answer
NAME OF ORGANIZATION *
The full name of the organization that you will be serving
Your answer
CITY *
Your answer
ORGANIZATION CONTACT PHONE OR EMAIL *
Your answer
NAME OF SUPERVISOR *
Your answer
Who will you be helping? *
Your answer
What service will you be performing to help those people, animals, or places? (Use verbs) *
Your answer
How will these people, animals, or places benefit from your help? *
Your answer
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) *
Your answer
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 *
Your parents name typed in this box signifies their approval of your participation in this activity. Your parents may be contacted by phone, email and/or text to verify their permission for your involvement in this activity.
Your answer
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