Class Of Choose your class 2009 2010

Student's Name: Select Name

Student's E mail address:

Agency/Organization Full Name:

Note: Community Service must be completed with an agency or organization, i.e. an individual's name entered above is not appropriate

Is the organization a Mariemont School District group/agency? Choose Yes No

Is the organization non-profit? Choose Yes No

If done through a church, how does the activity benefit the community at-large?

Date you plan to begin service (must submit prior to start date): - -

Estimated hours you plan to serve.  (List only digits, no punctuation or words) :   

Direct Supervisor's Name:     Phone Number:

Supervisor's E mail:

Brief description of service you plan to provide.  Key Phrase Only: