Kamehameha Schools Maui Campus

Data Entry Date____

Data Entry Initials____

Kamehameha Schools Maui Campus

270 ‘A’apueo Parkway

Pukalani, HI 96768

Community Service Verification Form

(Student fills out this portion)

Name: ______Class of: ______School Year: 20___-20____

Number of Hours spent at activity: ______Activity Date: ______

Name of Agency: ______

Supervisor in charge: ______Phone Contact: ______

Describe duties or responsibilities: ______

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Agency Verification (Supervisor of agency fills out)

Duties or responsibilities: ______

______

______

Signature of Person in charge: ______Date: ______

Contact number: ______

Comments: ______

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Do not write below this line.

Verification by counselor or school official

Name of person contacted: ______Phone number: ______

Counselor Approval of Activity:______Date: ______

“The best test, and the most difficult to administer is: Do those served grow as persons; do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?”

-Robert Greenleaf

Servant Leadership

Service Reflection

(Please answer the following questions before submitting the service form)

1.  Why did you choose to do this particular Community Service?

2.  How do you think the Community Service you did impacted the community?

3.  Do you feel this Community Service project was important?

4.  Summarize the most important things you will take with you from the experience?

5.  How did participating in this project make you feel?

6.  Would you do this Community Service again?