Anda di halaman 1dari 1

Office of Curriculum and Instructional Programs MONTGOMERy COUNTy PUBLIC SCHOOLS Rockville, Maryland 20850

STUDENT SERVICE LEARNING ACTIVITy VERIFICATION

STUDENT INSTRUCTIONS: Complete this form legibly in blue or black ink. Submit it to the school student service learning (SSL) coordinator according to the following timelines: Last Friday in September: Documentation of service performed in the summer is due. Friday before first semester exams begin: Documentation of service performed during the first semester is due. Friday before second semester exams begin: Documentation of service performed during the second semester is due. STUDENT INFORMATIONTo be completed by the student prior to review from the nonprofit tax-exempt organization. Name Donley
Last

Donley
First

L
MI

415631
ID Number

Parent/Guardian Adrena Brown School James Hubert Blake Student e-mail address sharne.latrice@gmail.com Grade 12

Phone: Home

301-273-3641

Work

202-510-2918

First Period Teacher Ms. Simms

Student Reflection: Think about your service-learning activity and respond to the following questions in a written statement below.

1. 2. 3. 4.

What need did your service address? Who benefitted from your service? What did you learn about yourself? How was your service-learning experience connected to something you learned in a class at school? (For example, English, Mathematics, Science, Social Studies, Arts, Physical Education, Health, Foreign Language, etc.)
1. Promoting awareness for the NBCC (National Breast Cancer Correlation) 2. Survivors of Breast Cancer 3. I learned that I was very good at working under a lot of pressure, and can get things done quickly and efficiently; while learning something new. 4.Health was directly related to this experience of course being in good health and taking care of yourself is important when you are facing breast cancer. Another subject connected would be foreign language; Spanish to be more specific. I learned about Spanish oriented non-profit organizations that promote awareness and fund research for breast cancer, which led to my realization that language is not a limiting factor in this important matter.

NONPROFIT TAX-EXEMPT ORGANIZATION INFORMATIONTo be completed by the supervisor after the phases of preparation and action have occurred, and the student reflection statement has been read and approved. Organization The Event Professionals Inc. Address 2330 Scenic Highway
Street City

Tax Exempt # -

Phone
State

770-760-9998 GA 30078
ZIP Code

Snellville

Activity (describe) Event planing and coordinator for the National Breast Cancer Correlation conference held on Saturday May 22

at the Renaissance Hotel located at 999 9th Street NW Washington. (Duties included: set up and breakdown, packaging etc.)
Service Record
From To # Days of Service # Hours Per Day (8 in a 24 hour period maximum) Total # Hours Completed (award 1 SSL hour for every hour of service)

Thursday
Supervisor Marva Lewis

Sunday

28

Coordinator
Print Name Signature, Supervisor Date Title

SSL COORDINATOR USE ONLy Check if automatic hours are attached to this activity as a result of course instruction.
Date

Verification form submitted to coordinator Hours earned previously

+ Hours for this activity

= Total hours including activity

Date

MCPS Form 560-51, August 2009

DISTRIBUTION: COPY 1/Student Service Learning Coordinator; COPY 2/Student; COPY 3/Organization

Anda mungkin juga menyukai