Blind Brook High School
840 King Street
Rye Brook, New York 10573

TIME VERIFICATION FORM

Service Organization: ______________________________________

Contact Person: ________________________________________please print

Signature: _____________________________________________

Title: _________________________________________________

Telephone: _____________________________________________

Name of Student: _______________________________________

Grade of Student: Circle please NINTH TENTH ELEVENTH TWELFTH

Hour(s) Completed: _____________________________________

Date(s) Completed: _____________________________________

Short Description of Service: _____________________________________

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Dear Student: Please print out and drop this sheet in Jane Romm's Community Service Mailbox in the Main Office at school.