Service Verification Form

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Please see the Good Counsel Handbook or http://www.olgchs.org/teachers/student-service/requirements.htm for service requirements and deadlines.

***To complete the following, copy the follow test and paste it into a Word document and return it to the Campus Ministry Office. Forms may be mailed to Community Service, Our Lady of Good Counsel High School, 17301 Old Vic Blvd. Olney, MD 20832

OUR LADY OF GOOD COUNSEL HIGH SCHOOL

XAVERIAN COMMUNITY SERVICE

SERVICE VERIFICATION FORM

NAME: _______________________________________________________

DATE: _______________________________________________________

STUDENT ID: ____________         GRADE: ________             COMMUNITY: ____________________________

ORGANIZATION SERVED: _____________________________________________________________

ORGANIZATION CONTACT NAME: ___________________________________________________________

ORGANIZATION CONTACT PHONE NUMBER/E-MAIL:_________________________________________

JRS & SRS ONLY: HOW DOES THIS ORGANIZATION SERVE THE POOR & MARGINALIZED

_____________________________________________________________________________________________

_____________________________________________________________________________

SRS ONLY:  HOW DOES THIS FIT THE COHESIVE THEME OF YOUR 40 HOUR REQUIREMENT:  

_____________________________________________________________________________________________

TO BE COMPLETED BY SUPERVISOR:

SUPERVISOR SIGNATURE : ___________________________________________________________________ 

COMMENTS: ________________________________________________________________________________

_____________________________________________________________________________________________

______________________________________________________________________________

Please return this form to the Campus Ministry Office.

Last updated September 5,  2007

For information on the Campus Ministry Department go to http://TeacherWeb.com/MD/GoodCounsel/CampusMinistry