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LANCASTER CATHOLIC HIGH SCHOOL GOOD SAMARITAN PROGRAM A SERVICE/LEARNING PROGRAM (REVISED: SEPTEMBER 1, 2015)

OFFICIAL SERVICE/LEARNING DOCUMENTATION FORM 2015-2016 STUDENT NAME: __________________________________________________________

THEOLOGY TEACHER: _____________________________________________________

YOG: ___________________

(Section below to be completed by a representative of the organization ONLY!)

Dates of service organization: ______________________________ Total Hours: ___________

Name of service organization: _______________________________________________

Contact phone number of organization: ________________________________________

Briefly describe what the student did in this service and how it helped your organization: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________

Signatures affirm the above information is accurate and true.

______________________________________________________ Date: _____________ Organization Supervisor Signature

___________________________________________________________ Date: _____________ Student Signature

___________________________________________________________ Date: _____________ Parent/Guardian Signature

LCHS Good Samaritan Program Form