CARLSBAD HIGH SCHOOL

3557 Lancer Way

Carlsbad, CA 92008

(760) 331-5100 FAX (760) 729-6830

Community Service Program

Student Form

This form is to be completed by the student and returned to the Guidance Office.

Student ID Number: ____________

Student Name: _________________________________________________

(PLEASE PRINT) Last First

Year of Graduation: _______

Name of Service Site:

______________________________________________________________

Address: ________________________________________________

Phone#: ______________________________

Supervisor Contact: ________________________________

(PLEASE PRINT) Last First

Supervisor’s Signature:_______________________________

(Please attach Business card)

Hours Completed: ____________

If this Community Service is not on the pre-approved sample list, administrative approval is required.

Administrative Approval: ______________________________

Date: _________________________________

Student Signature: _________________________________

Date: ___________

RETURN THIS TO GUIDANCE OFFICE

Recorded: ______