HISP Program

Community Service Report Form

Name:__________________________________________________________Date:_____________________________

Class:__________________________________________________________Period:____________________________

STUDENT: Fill out one of the following forms for each type of service you performed. If you 

need more, duplicate this sheet. Please do not just write out another form on the back.

1. Name of agency _________________________________________________________

or person served:__________________________________________________________

Address:________________________________________________________Phone____________________________

Date and Hours(e.g.2:30-4:00)Served:______________________________________________________________

Describe what you did:______________________________________________________________________________

________________________________________________________________________________________________

Are you receiving any money or other credit for this service?__________________________________________________

SIGNATURE OF THE SUPERVISING ADULT:______________________________________________________________

2. Name of agency _________________________________________________________

or person served:__________________________________________________________

Address:________________________________________________________Phone____________________________

Date and Hours(e.g.2:30-4:00)Served:______________________________________________________________

Describe what you did:______________________________________________________________________________

________________________________________________________________________________________________

Are you receiving any money or other credit for this service?__________________________________________________

SIGNATURE OF THE SUPERVISING ADULT:______________________________________________________________

3. Name of agency _________________________________________________________

or person served:__________________________________________________________

Address:________________________________________________________Phone____________________________

Date and Hours(e.g.2:30-4:00)Served:______________________________________________________________

Describe what you did:______________________________________________________________________________

________________________________________________________________________________________________

Are you receiving any money or other credit for this service?__________________________________________________

SIGNATURE OF THE SUPERVISING ADULT:______________________________________________________________