DELTA SIGMA THETA SORORITY, INC.

AService Sorarity Grand Chapter

VERIFICATION OF SERVICE FORM

As a requirement of the membership application, Delta Sigma Theta Sorority, Incorporated requires the applicant to submit a Verification of Service form for each organization that will veriff volunteer service pmvided to that organization. Please complete this form. If additional space is required, attach your eryanded and/or additional responses on a separaG sheel ;

Applicant Name:
Name of Organization: Services applicant has provided to organization:

Dominique Ricks, ForKids Dominique Ricks, ForKids

tutoring, mentoring

Name and contact information of person

with direct knowledge of the service provided by applicant:

Name: Melanie Romano-Mason

Please describe the service rendered and

Email:

mromanunason@turkidwa.org

Telephone= rclazzuo0 ext nization?

12g

s roles and

ibilities with

help tutor and provide remedial education services to students who aftend our program and serve as role model/mentor to students

ADDffiONAL INFORTTIATION TO BE ATTACHED TO THE FORII{ (OpTIONAL): If applicable, please attach a Certificate of Good Standing from the Secretary of State for your ization or evidence of non-profit status.
The res@nses

the following questions are to verifv the

applimtts vohmteer

senrice

with your organization

What do your records show as the length of time the applicant has been involved in your organization?

L
Plese -Years

uon$s

daB ofservice

Le.

Mard 2011-

Please

the a

involvementinthe

provided remedial education services and helped tutor students in our program

Revised

06/12

Was the service that was provided by the applicant in line with the mission and purpose of nfromthe : and what did the

your

Dominique helped provide tutoring and educational services to students. She consistently attended our program with a positive attitude and willingness to help the students.

Atanytime duringthe period of service was the applicant ever paid/compensated for services providfr?
No

YES

f]

IfYES, Please Explain:

N/A

Additional Comments /lnformation:

N/A

tame of Person CompletingFonn

Signature

ThmtkYou!!!

Delu SignaTlteta Sorority,

Irrc.
Revised

05/12