MCPS Form 560-51
September 2018
Student Service Learning Activity Verification
Office of Student and Family Support and Engagement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
STUDENT INSTRUCTIONS:
Complete Sections I and III of this form legibly in blue or black ink. The nonprofit tax exempt organization completes Section II.
Documentation of all service is due to the school-based SSL coordinator according to specific timelines. In order to be reflected on the student’s report
card each semester, students must submit MCPS Form 560-51, Student Service Learning Activity Verification Form, to the school SSL coordinator by the
following recommended dates:
Service completed during the summer—Recommended by Last Friday in September
Service completed during the summer and 1st semester—Recommended by First Friday in January
Service completed during the summer, 1st semester, and 2nd semester to be recognized for the Certificate of Meritorious Service (high school
seniors) or the Superintendent’s SSL Award (middle school)—Recommended by First Friday in April
Service completed during the summer, 1st semester, and 2nd semester—REQUIRED by First Friday in June
ALL SSL Forms for service completed any time during the current school year, including the summer before the current school year, are REQUIRED
to be submitted to the school SSL coordinator no later than the first Friday in June.
SECTION I. STUDENT INFORMATION—
To be completed by the student prior to review from the nonprofit tax exempt organization.
Student Name (Last, First, Middle)
____________________________________________________________ Student ID _________ Grade _____
School
______________________________________________________ First Period Teacher_____________________________________________
E-mail
____________________________________________________________________________________________________________________
Parent/Guardian Name _________________________________________Phone: Home or Cell _____-_____-______ Other _____-_____-______
SECTION II. NONPROFIT, TAX EXEMPT ORGANIZATION INFORMATION—To be completed by the supervisor after the phases
of preparation and action have occurred.
Organization
________________________________Federal Employer Identification # __ __- __ __ __ __ __ __ __ Phone _____-_____-______
Address
___________________________________________________________________E-mail___________________________________________
Describe Activity (performed)
________________________________________________________________________________________________
Service Record
Date From Date To
# Days
of Service
# Hours Per Day
(8 in a 24 hour
period maximum)
Total # Hours Completed
(award 1 SSL hour for
every hour of service)
Supervisor Name (print) ____________________________________________________ Title____________________________________________
Supervisor Signature
____________________________________________________________________________________Date ____/____/_____
SECTION III. STUDENT REFLECTION—
T
hink about your SSL activity. Review the Maryland Seven Best Practices of Service-Learning
www.montgomeryschoolsmd.org/departments/ssl/pages/bestpractices.aspx and respond to the following questions in a written paragraph below,
or attach a separate document with your reflection.
• What did you do?
• What need did your service address?
• Who benefitted from your service?
• What did you learn about yourself?
• How was this experience connected to something you learned in a class at school? (For example, English, Mathematics, Science, Social Studies, Arts,
Physical Education, Health, Foreign Language, etc.)
Note: This reflection will be reviewed by the MCPS SSL coordinator and returned to the student if not complete.
Parent/Guardian/Eligible Student Signature ________________________________________________________________Date ____/____/_____
MCPS SSL COORDINATOR USE ONLY
o Check if automatic hours are attached to this activity as a result of course instruction.
Verification form submitted to coordinator
Date____/____/_____
Hours earned previously + Hours for this activity = Total hours including activity Date ____/____/_____
