1 June 2007 to 31 Dec 2007

for Eligibility to NJHS

Name: _______________________ Grade: ___ Semester: ________

1. Organization’s Name: _____________________________________________________

Service Performed: ________________________________________________________________________

________________________________________________________________________

Supervisor’s Printed Name, Signature and Phone #: ___________________________________________________

Date Project Completed: _______________ # of Hours: _____

2. Organization’s Name: _____________________________________________________

Service Performed: ________________________________________________________________________

________________________________________________________________________

Supervisor’s Printed Name, Signature and Phone #: ___________________________________________________

Date Project Completed: _______________ # of Hours: _____

3. Organization’s Name: _____________________________________________________

Service Performed: ________________________________________________________________________

________________________________________________________________________

Supervisor’s Printed Name, Signature and Phone #: ___________________________________________________

Date Project Completed: _______________ # of Hours: _____

4. Organization’s Name: _____________________________________________________

Service Performed: ________________________________________________________________________

________________________________________________________________________

Supervisor’s Printed Name, Signature and Phone #: ___________________________________________________

Date Project Completed: _______________ # of Hours: _____

5. Organization’s Name: _____________________________________________________

Service Performed: ________________________________________________________________________

________________________________________________________________________

Supervisor’s Printed Name, Signature and Phone #: ___________________________________________________

Date Project Completed: _______________ # of Hours: _____