To be completed by student volunteer - PLEASE PRINT OR TYPE
Name: __________________________________________________ Student Number: __________________________________
Address: ____________________________________________________________________________________________________
Phone: __________________________________________________ Emergency Phone: ________________________________
Grade Level: _____________________________________________
Usual Method of Transportation: _________________________________________________________________________________
Student Pledge: I agree to fulll the duties and time commitments as listed in the agency job description including training sessions and
to provide adequate notice if I am unable to meet my commitments. I also agree to adhere to the roles and procedures of the agency at
which I am volunteering.
Student Signature: ________________________________________ Date: ____________________________________________
To be completed by agency volunteer coordinator/director or individual supervising the project - PLEASE PRINT OR TYPE
Name of Agency: ______________________________________________________Company 501.c3 Number: _________________
Address: ____________________________________________________________________________________________________
Phone: __________________________________________________ Operating Hours: __________________________________
Contact Person: __________________________________________
Title/position: ________________________________________________________________________________________________
Days and hours scheduled for the student Volunteer: ________________________________________________________________
Brief description of the job(s) to be performed by the student: ________________________________________________________
Certicate of Insurance on le: __________________________________________________________________________________
Contact Person Signature: __________________________________ Date: ____________________________________________
To be completed by parent/guardian - PLEASE PRINT OR TYPE
I give permission for _______________________________________________ to serve as a volunteer for the agency/project
indicated above on the stated days and for the stated hours.
I understand that he/she will
be making a valuable and needed contribution to our community. I also understand that he/she
will not receive monetary compensation for his/her services.
We have accident insurance with ______________________________________________ (name of insurance company) which
will cover my son/daughter/ward in the event of injury while engaging in this activity. I will assume responsibility for expenses
incurred as the result of any injury my son/daughter might suffer while participating in this activity. If a change occurs in the
policy, it is my responsibility to notify the school’s principal or Student Volunteer Service Program coordinator.
Parent/Guardian Signature: _________________________________ Date: __________________________________________
To be completed by Student Volunteer Service Program Coordinator - PLEASE PRINT OR TYPE
For hours to be awarded in an attempt to meet the Service Learning Graduation Requirement or to earn a Silver Cord the Application
and Approval Form must be completed and submitted to the school’s Student Volunteer Service Program Coordinator. It is best if
this is done prior to starting the activity described in Part B.
Student Volunteer Service Program Coordinator Signature: ___________________________________________________________
Date Received:: ___________________________________________ Date Approved: ___________________________________
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