The Palos Verdes Assembly
Volunteer Community Service Form
(Print Version)
Member Name_____________________________________Grade________
Service Organization Name & brief description of their main purpose:
___________________________________________________
___________________________________________________
Date of your community service: ____________
Time started: ________________
Time ended: ________________
Total Hours: ________________
Description of your services performed:
____________________________________________________ ____________________________________________________
If you baked cookies; how many dozen(s) you baked: _______________________________
Name & Title of Organization’s Contact: __________________________________________
Contact Number: (___)____________________________________________
(will be verified)
FORM SUBMITTAL: Place in the Community Service Basket at any Assembly dance or mail to: The Palos Verdes Assembly, P. O. Box 3103, PVP, CA, 90274; Attention: Community Service
LAST DAY TO SUBMIT HOURS: March dance. No Exceptions! Any forms received after this date will be credited toward the next year. If you wish to earn a certificate from Assembly recognizing your service contribution you must perform at least 20 hours each year. To receive a Community Service Medallion at the Presentation Ball a minimum of 80 hours must be performed during your four (4) year participation. This form needs to be submitted in order to receive credit!
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