Douglas Anderson Community Service Plan

Bright Futures Scholarship/Silver Cord Requirement

Complete and submit this form if you are unsure about whether the community service you want to do or have done will count

IDENTIFY A SOCIAL PROBLEM - I have indicated with an "X" the social problem I plan to address (see reverse side for a
description of possible social problems to address).
Service to Youth ( Early Childhood ages birth to 12 years, At Risk Youth ages 13 to 18)
Quality of Life
Service to Senior Citizens
Health/Safety
Special Needs (developmentally disabled and/or physically disabled
Environment and/or Historical Preservation
Arts/Culture
Other (You may choose to address a social problem other than those above. Describe your choice on below line)

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II. WRITTEN PLAN FOR PERSONAL INVOLVEMENT WITH THIS SOCIAL PROBLEM: (50 words or less)

III. MY EVALUATION AND REFLECTION OF THE EXPERIENCE: (100 words or less)

Parent's Signature Date

Student' Signature Date
Designee's Signature Date