McComb High School Service Learning Completed Service Form

THE UPPER PORTION OF THIS FORM SHOULD BE COMPLETED BY THE STUDENT PRIOR TO SUPERVISOR’S EVALUATION AND SIGNATURE

Personal Information:

Student Name: _________________________________________	Date(s) Worked: _________________________

Graduating Class of 20_____. (Fill in your graduation year)

Service Information and Reflection:

Organization: __________________________________________	Type of Service: ___________________________

How did the service benefit others? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Total Hours Worked: ___________

Supervisor Evaluation of Student’s Service (if applicable): I would rate this student’s work as:
_________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Additional Comments: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Supervisor’s Signature: ________________________________________________

To the supervisor: The information given on this evaluation sheet will be used to determine whether this student has successfully completed the credit requirements of the service program at McComb High School. Please be honest in your evaluation and comments. If you do not wish for the student to see your remarks, please indicate so by checking this blank __________. Thank you.

Please return form to:

McComb High School, Attn: Service Learning, 328 S. Todd Street McComb Ohio 45858 or to Mrs. Teegardin at Teegardink@mccombschool.org.