Belleville West High School

4063 Frank Scott Parkway West

Belleville, Illinois 62223

(618) 222-7500

To be completed by the student:

Student Name_______________________________________ Phone______________________________

Due Date: September 21, 2007 Adviser:___________________________________________________

Agency:___________________________________________________________________________________

General description of the service you will be providing:

I am aware that the completion and documentation of hours is my (the student) responsibility. I understand that the agency will not be contacting me for the hours, but rather I will take the responsibility to schedule my time in such a manner that the February 29, 2008 deadline will be easily met. I also understand that my hours must be served working with people rather than through “office work” or concession. I understand that this form is due September 21, 2007. It must be delivered and signed for with the appropriate sponsor.

Student signature____________________________________________________________ Date___________________

Parent/Guardian signature_____________________________________________________ Date___________________

To be filled out by the agency:

This is to certify that ______________________________________________________________________ (agency name) will be able to provide ___________________________________________________________ (student name) with opportunities that will enable him/her to complete 25 hours of community service by Thursday, February 28th , 2008.

Signature of contact person________________________________________________________ Date___________________

Printed name and Title of Contact Person__________________________________________________________________________

Phone number of Contact Person ________________________________________________________________________________

Anticipated dates of hours to be completed. This does not need to be specific, just a general time frame (month, time of day, etc). Please discuss this with the student so that he or she can make sure that they have no scheduling conflicts.

Dates:

To the contact person: Thank-you for providing us with this opportunity for the students of BTHS West NHS. If you have any questions or concerns please contact Brandon Hentze, or Lisa Quandt at the number above. We recommend that you make a copy of this contract for your records. Please feel free to place any comments about the student, the contract, or the program on the reverse of this form.