BLOCK DC SCHOOL SERVICE FORM

7.5 hours required each semester

Due May 6, 2024 (staple to Block DC application)

Students may not work more than 30 minutes/day.

Student Name: _____________________________________Room Number: _______________

Activity: __________________________ Approved by (Signature of Staff): _________________

*Students are encouraged to complete 38 minutes each week to stay on track. *

Week | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Total Hours
1/22/24 | | | | | |
1/29/24 | | | | | |
2/5/24 | | | | | |
__________ On Track	__________Not on Track (student verbally warned)

*Students are encouraged to complete 38 minutes each week to stay on track. *

Week | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Total Hours
2/12/24 | | | | | |
2/19/24 | | | | | |
2/26/24 | | | | | |
__________ On Track	__________Not on Track (student verbally warned)

*Students are encouraged to complete 38 minutes each week to stay on track. *

Week | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Total Hours
3/4/24 | | | | | |
3/11/24 | | | | | |
3/18/24 | | | | | |
__________ On Track	__________Not on Track (student verbally warned)

*Students are encouraged to complete 38 minutes each week to stay on track. *

Week | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Total Hours
4/1/24 | | | | | |
4/8/24 | | | | | |
4/15/24 | | | | | |
4/22/24 | | | | | |
__________ On Track	__________Not on Track (student verbally warned)

Student Signature_________________________	Teacher Signature________________________