Community Service Reflection Form

9th/10th Graders ONLY!

Please complete in blue or black ink!

Student Name: _________________________________________________ Grade: _______

ID Number: ____________________

Name of Activity: _______________________________________________________________

Date of Activity: ___________________ Number of hours: _________

“Service involves interaction, such as the building of links with individuals or groups in
the community…”

1. What link did you build and how did it benefit others?

____________________________________________________________________________

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“Service should not only involve doing things for others, but also doing things with
others and developing a real commitment with them.”

2. Explain how you worked with others and developed a commitment with them.

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“Generally CAS is not taking place when a student is in a passive rather than an active
role.”

3. Explain your active role in your service activity.

_____________________________________________________________________________

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“Generally CAS is not taking place if no real reflection is possible.”

4. Reflect on your contribution to your personal development and the community.

______________________________________________________________________________

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5. If this service activity is over 10 hours, you MUST provide a log of dates and
times of service. This log MUST be turned in monthly!

To be completed by the Activity Supervisor (an adult who is not related to the
student):

Comments on student’s performance:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Activity Leader’s Name (Printed): _____________________________________________

Activity Leader’s Signature:___________________________________________________

Date of activity:_______________________

Agency/organization (if applicable): _________________________________________

Contact Phone Number: _________________________