To the agency: Thank-you for taking the time to fill out this form for the Belleville West National Honor Society. As part of the NHS, students must complete at least 25 hours of community service. We feel that this provides our candidates with a great opportunity to help give something back to their community as well as develop leadership roles. The guidelines for community service as follows:

·                The students must be able to complete at least 25 hours of active service (not including transportation time)

·                All service work must be completed by September 7, 2007.

·                The student should experience things outside of their “comfort zone” of everyday experiences, not continuing to perform the same service work that they have in the past

·                As much of the work possible should be done with people

·                Office work, concession work, etc. are not considered community service and cannot be accepted

·                The student should be provided with a safe working environment

•         If the work is done with a church of youth group, it should be secular (meals on wheels, food pantry, etc) as opposed to   

               religious (Sunday school, acolyte, etc.)

Please briefly describe the type of work that the student would be doing:

Briefly explain how this will be outside the student’s “comfort zone” and involve working with people:

What dates and times would you be able to provide service opportunities?

Would you like to make your agency available to all students?

Would you like to be added to our list of service agencies that is provided to candidates each year?

Is there a limit to the number of students you can accept, and still guarantee 25 hours of active service for each?

Name of contact person and the agency:_______________________________________________________

Title of the contact person:________________________________________________________________

Phone number:__________________________________

Address_________________________________________

            _________________________________________

            _________________________________________

Name of student(s) requesting agency

Completion of the agency application does not guarantee it will be accepted as appropriate for NHS community service.  The sponsors will notify the student of their decision.  All decisions are final.  If you have questions, please feel free to contact any of the NHS sponsors, Mr. Brandon Hentze (student last names A-K) or Mrs. Lisa Quandt (student last names L-Z) at (618) 222-7500.  Thank-you again for taking the time to complete this form.  Please return by Friday, September 7, 2007.