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2020-2021
Student Service-Learning Verification Form
During COVID -19 Period Only
Complete this form in blue or black ink and submit to the School-Based Student Service-Learning Coordinator.
Submission Deadlines for this Student Service-Learning Verification Form:
This form is only permitted to be used for the period of COVID-19
______________________________________________________________________
Section to be completed by the student:
Student Name: _____________________________________________ S
tudent Number: __________________________
School: ____________________________________________________Student Telephone: ________________________
Student Mailing Address: ______________________________________________________________________________
City: _______________________________________ State: __________________________ Zip: ___________________
Email: __________________________________________ Grade in school __________________
Remember that any Student Service-Learning independent activity must meet the Maryland State Department of
Education’s 7 Best Practices and include preparation or research, action, and reflection:
✔ The Student Meets a Recognized Need in the Community.
✔ The Student Achieves Curricular Objectives.
✔ The Student Gains Necessary Knowledge and Skills.
✔ The Student Plans Ahead.
✔ The Student Works with Existing Service Organizations.
✔ The Student Works with Existing Service.
✔ The Student Reflects Throughout the Experience.
✔ Student Assessment of Service-Learning Activity
I. Describe your preparation for the service-learning activity/activities that allowed you to help others during the
COVID-19 outbreak? Share what research you did to help prepare and what you learned:
ll. Describe the service-learning activity/activities.
III. Share how people were impacted by your efforts. If you worked with an organization, please include the name of
organization and the person who oversaw the activity.
