Gateway High School

Community Service Program

 

 

Student Name:________________________ Date: __________________

Advisor: ____________________________________

Grade: 9 10 11 12 (Please Circle)

Dates of Service: _____________________________

Number of Hours: ___________________________

Name of Agency/ Organization: __________________________________

Address: ____________________________________________

Phone Number: _______________________________________

Name of Supervisor (please print): _______________________

Signature of Supervisor: _______________________________

Signature of Student: __________________________________________

Signature of Parent: ___________________________________________

 

Please return completed forms to the Community Service Box in the main office.