Cole Elementary

Block C - Community Involvement Form Use One Form for Each Community Activity Point

Student: _____________________________ Grade____ Teacher _______________ Room ___ (Please print name clearly.)

During this school year, I have participated in:

o Community Arts (Counts for Spirit: Performing and Fine Arts) o Community Sports (Counts for Body: Athletics)
o Worked for Two Hours at a School Event (Counts for Spirit: Leadership & School Service) o Community Service Involvement (Counts for: Community Service Involvement Bonus
Point)

I hereby request that the above checked item count toward my Block C points as
sponsored by ___________________________________________ during this school year. Name of sponsoring organization or supervisor

My leader, coach, supervisor or teacher in this organization, team, or class has judged my participation to be satisfactory as certified by his/her signature below. This activity meets the criteria for a Block C point as outlined in the Block C Handbook.

_____________________________ Student Signature

______________________________ Parent/Guardian Signature

SPONSOR CERTIFICATION

I certify that the individual named above has actively participated in a consistent and acceptable manner. I recommend that s/he be granted credit toward the Cole Block C Award for the activity listed above. If you have any questions, you may contact me at this phone number: _________________________.

_______________________________________________ Print Name	Signature

______________________________________________ Name of Organization

__________________ Title

__________________ Date