Community Service Learning Program Application

District of Columbia Courts

Community Service Learning Program Application

PLEASE TYPE OR PRINT

STUDENT INFORMATION:
Name (Last, First, Middle): / Date:
High School: / Current Grade:
Email Address:
/ Home Phone: / Cell Phone:
Home Address:
Number of Community Services Hours
needed to meet graduation requirements:
RECOMMENDATION:
Print Name: / Title:
Signature: / Date:
School Name:
Email Address: / Phone:
PREVIOUS COMMUMITY SERVICE PROJECTS: (if any)
Organization Name: (1) / Supervisor:
Responsibilities: / Phone:
Total Hours Earned:
EMERGENCY CONTACT INFORMATION:
Parent/Guardian Name: / Phone:

I certify that the information above is true and complete to the best of my knowledge. I hereby state that I do not have an active Juvenile case within the District of Columbia Courts. If this application leads to active community service, I understand that false or misleading information on my application may result in dismissal from the program.

Applicant Signature: ______Date: ______

Parent/ Guardian Signature:______Date: ______