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.
Service-Learning Log
at Date of Service
Name of Activity
Hours of Service
( (For example, 3:15 p.m. - 4:15 p.m.)
Total Hours
Upon reflection, what did you learn about yourself and others?
________________________________________ ______________________________________________
Student’s Signature Parent or Guardian’s Signature
________________________ ________________________
Date Date
For School-Based Student Service-Learning Coordinator and data-entry personnel use
Previous Independent Hours
+ Independent Hours for this activity
= Total Independent Hours
Date of receipt __
Title _____________________________________________________
*Once completed, the Student Service-Learning Verification form needs to be
scanned to School Counselor to be entered into SchoolMax and placed in the
student’s cumulative folder.