Community Service Documentation Form
(2009-2010 school year)
Student Learning Endorsement: Cullman High School students that complete 100 hours of service will receive a
service hour stamp on their diploma. The purpose of this service learning initiative is to reach out to our community
and to instill a lifelong dedication to service.
Requirements: At least 50 % of the hours must be obtained from a registered non-profit organization. Cullman High
School will not recognize hours completed with organizations that are managed or owned by the student’s family. All
hours must be documented on a Community Service Documentation Form. The completed form must be returned to
the Guidance Office by the last school day in April 2010.
SOURCE: Cullman City Board of Education, Cullman, AL ADOPTED: 12/2007
This is to certify that __________________________________ from Cullman High School Class of _______________
(name of student) (graduation year)
has performed volunteer service on the date and location listed below.
Name of Organization / Non-Profit / Event: ____________________________________________________________
Date of Event Time In Time Out Total Hours Per Day
Specific Duties / Services Performed:
Supervisor Name (please print): _____________________________________________________________________
Supervisor Signature: _____________________________________________________ Date: _____/_____/_______
Address (if different from above): ___________________________________________________________________
Phone Number: _________________________ E-mail Address: ________________________________________