Jefferson Elementary School Block J Award
Community Service Involvement Verification Form

Student Name: ______________________________________________

Grade: _______ Teacher:________________________	Room #:__________ Semester (circle one) : First	Second

Dear Advisor,

The above-named student is working to earn the Block J award. This is the highest award a student may earn at Jefferson Elementary School. In pursuing this award, a student may earn credit for performing at least four hours of community service per semester. Examples of community service include Boy/Girl Scouts, Indian Guides/Princesses, Good News Club, church-sponsored activities, visits to retirement homes, or other activities serving charitable and/or non-profit organizations.

This student is asking to receive credit for the following community service activity (to be completed by student):

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By signing this form, you are certifying that the student has successfully completed at least four hours of community service during the noted semester and will be awarded 1 point toward the Jefferson Block J Award for this current semester.

Community Service Advisor:____________________________________________

Parent Signature: ____________________________________________________

Date:______________________

Date:______________________

***This form needs to be turned in and approved by your teacher or Block J Advisor when you turn in your Block J sign-off sheet. You may staple and attach this to your other form.

Approved by teacher/ Block J Advisor