Community Service Learning Project Form

Cocheco Valley Humane Society, 262 County Farm Rd, Dover, NH 03820   Phone: (603)749-5322 

Attention: Jane Kennedy, Humane Education

Community Service Project Submitted By_______________________________ Age __Grade ___

School Contact Person_______________________________

School _______________________School Contact's Phone #_______

Parent's Name______________________     Home Phone______________

Home Address______________________ City ____________State_________

Email Address__________________________

Date:  ______________  Cell Phone: (optional)__________________________

Project Estimated Completion Date:  __________

Hours to be earned at the completion of the project________________

Project Name and Description:  Please Be Specific________________________

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Student's Signature___________________________________  Date_______________

School Contact's Signature_________________________________________________

CVHS Contact's Signature_________________________________________________

Parent's Signature (if under 18 yrs of age)______________________________________