DUBOIS AREA SCHOOL DISTRICT Senior High School COMMUNITY SERVICE FORM # Studentname CUSHE Conc Grade SO ck. Home Phone Number <"I\ -O.e|__ student cel phone number abs = JB OG Jp Paren/euardian Showy Cone 4 Parent/Guardian CellPhone Numbers LiS-IO59 wo 3 1B 27h ‘Aaency/Site Requested a. Sahoo! agency Conta person inca RankuS phone 3 7/=S111 ‘Signature of Agency Contact: Anka. rt pate /0//9//3- ‘Students: Upon faifling of your community service hours, please have the agency supervisor complete the bottom portion of this form and return it along witha brief paragraph reflecting your community service experience to Mrs. McCleary, DAHS, room 128 or the Main office * AC_Cuugs has completed £ fours of eommunity serve x Diears Agca High Scheatiereiped mtn the ttowieg ia pokes: Thick oe Thear Event Supervisor's Signature Mkorke 6) one 20/17 // 3. “OAKS Authorization ate : ization is nee reaper it f re to have a now approved may result completed hour