Date of Organization’s Hours of Total Hours Signature of Supervisor/Teacher Name Service Service Earned Upon reflection, what did you learn about yourself and others? __________________________________________ _________________________________________ Student Signature Parent/Guardian Signature __________________________________ ___________________________ Date Date For School-Based Student Service-Learning Coordinator and data-entry personnel use only: Previous Independent Hours ______________ + Independent Hours for this activity ______________ = Total Independent Hours ______________ Date of receipt _ Signature:__________________________________________ Title: ______________________________________ Department of Curriculum and Instruction - Revised 4.30.12 Attachment 1 to A.P. 6151
Date of Service Organization’s Name Hours of Service Total Hours Earned Signature of Supervisor/Teacher Upon reflection, what did you learn about yourself and others? __________________________________________ _________________________________________ Student Signature Parent/Guardian Signature __________________________________ ___________________________ Date Date For School-Based Student Service-Learning Coordinator and data-entry personnel use only: Previous Independent Hours ______________ + Independent Hours for this activity ______________ = Total Independent Hours ______________ Date of receipt _ Signature:__________________________________________ Title: ______________________________________ Department of Curriculum and Instruction - Revised 4.30.12 Attachment 1 to A.P. 6151
MLK%20Agenda%20Book%202015-2016.docx