211 Info Bank

211 Summer of Service Online Service Journal

Click here for a printable version of this form.

Student Information
Student Name:
Street Adress:
City / State / Zip:
Phone:
E-Mail:
School:
School District:
Grade Level (upcoming year):
School Phone:
Agency Information (if applicable)
Agency Name:
Mission:
Street Address:
City / State / Zip:
Contact Person:
Phone:
Project Information
Project Date(s):
Student's total number of service hours:
Number of volunteers (if more than one):
Total number of hours for all volunteers (if more than one):

Service Story What did you do? What were the results? Use numbers, such as; "visited 5 seniors," "raised $100," or "cleaned up 10 bags of litter."
Service Impact What did you learn? How did you feel?
Additional Information
Images Please attach pictures of your service, if available.