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Name: Date: _________________ Grade Level: _______
Helias Service Hours 2012-2013 School Year year of graduation
Class of ’13 36 hours by Christmas break of 2012, Class of ’14, '15, '16 50 hours by Christmas break of Christmas break of senior year.
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Date
service
performed
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List the non-profit Agency**: place you worked
Describe the work done
No work may be done for individuals, ie: Family members, neighbors, babysitting.
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Hours completed
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Name of Contact Person
email or phone number where the person can be reached
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Valid signature only by contact person listed
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** A list of approved agencies can be found on the website with this form. If an agency is not listed, you may request approval to add one by emailing the campus minister at Helias Catholic High School, cbaker@heliashs.com. Please be sure to include name of agency, the work they do, contact person in charge of volunteers, number and work the agency does. 5/23/11 – revised
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