TWIN VALLEY HIGH SCHOOL SERVICE LEARNING PROGRAM
Verification Form

STUDENT INFORMATION
Student Name _____________________________ YOG ______ Advisor _________________
Placement Organization/Qualified Individual_________________________________________
Description of Service Activity ___________________________________________________

Supervisor’s Name & Phone No. __________________________________________________
Date(s) of Service ______________________________________________________________
Total Number of Hours _________________________

VERIFICATION
I certify that the above-named student has performed the number of service learning hours indicated above without compensation.

Supervisor’s signature ___________________________________ Date _______________
Supervisor’s comments (optional)

I certify that I performed the number of service learning hours indicated above without compensation.
Student’s signature ___________________________________ Date _______________
Student’s comments (optional)

COMPLETE THIS FORM AND RETURN IT TO YOUR ADVISOR. Forms should be submitted within one month of completion of the service activity. Forms MUST be submitted within three months of the completion of the service activity.

STUDENT JOURNAL
On the back of this sheet or on a separate sheet, write a reflective journal entry about your service project. Reflections must include (but are not limited to) answers to the following: What impact did your service have on others? What impact did it have on you? Would you recommend this activity to others? Why or why not?