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Community Service Form


Brock’s Gap Intermediate School

Record of Community Service Hours


Name ________________________________________________ Grade _________________


Homeroom Teacher ______________________________________


Community Service is defined as those activities which assist others or the community for which the student receives neither pay nor academic credit.  


Suggested Activities includes:  tutoring, yard work for an elderly neighbor, being a “mother’s helper” for small children other than your family, library volunteer, homeless shelters, Humane Society, church nursery, environmental projects, etc.  


This form should be turned into either Mrs. Robichaux or Mrs. Coleman by May 5, 2017.

Thirty (30) hours of service are required to earn an award.

Date of Activity

Community Service Location/Activity

Hours Logged

Signature of Service Supervisor




Total Number of Hours ___________________


I agree that I have performed the above hours.  


__________________________________________________        ______________________

Student Signature                                                                              Date


_______________________________________________                ______________________

Counselor Signature                                                                         Date