Community Service Credit Forms

Community Service Student-Initiated Project (CSSIP) Parent/Guardian Approval Form
I have discussed the Community Service SIP credit option with my son/daughter/ward and support his or her
participation in this credit option in the following community service activity.
I am aware:
 that participation by a student in a CSSIP activity may, but will not necessarily, be recognized by the school for credit,
and that whether a credit will be recognized and the level of credit that will be recognized will be based on the civic
knowledge, skills, and attitudes that are obtained by the student in the activity, which will be evaluated and
confirmed by the school based on the student’s participation and completion of the activity
 that a maximum of one (1) community service credit can be earned, which can be used towards the total number of
credits required for graduation
 that participation by a student in a community service activity prior to him or her obtaining permission from the
school to proceed with the activity cannot be applied towards a CSSIP credit
 that a community service activity will not be recognized for a CSSIP credit where the activity involves assisting
immediate family members
 that in order for a community service activity to be recognized for a CSSIP credit, no payment(s) can be accepted by
the student
 that court-imposed community service cannot be used for the CSSIP credit
 that participation by a student in a community service activity for a CSSIP credit is a private activity outside the
regular school program
 that a student who participates in a community service activity for a CSSIP credit option is not enrolled in a course
nor is he or she performing work that is part of a course that is approved by Manitoba Education, and is not engaging
in a work education program nor participating in a program conducted off the school premises under the authority of
a school board
 that in evaluating the community service activity prior to the start of the activity by the student, the school will
evaluate only the civic knowledge, skills, and attitudes to be obtained by the student in the activity and will not
evaluate any hazards that may be associated with the CSSIP activity
 that neither the school, nor the school division, nor Manitoba Education will be liable for any injury to the student or
for any damage to or loss of property of the student caused by or in any way related to the student’s participation in
a CSSIP activity
 that a student and his or her parents/guardians bear the responsibility for the student’s safety. A student should
discuss concerns about the nature of the community service activity with his or her parents/guardians and, together,
they should exercise discretion, be aware of safety issues, and investigate the community organization’s or group’s
liability insurance coverage for volunteers before deciding that the student will participate in the CSSIP activity
 that a student may withdraw from the community service activity at any time for any reason, including for the reason
that the CSSIP activity workplace conditions are not acceptable to the student or to their parents/guardians.
I have read and understand the above information.
__________________________________________________ ________________________________
Signature of Parent/Guardian Date
__________________________________________________ __________________________________
Signature of Student Date

Community Service Student-Initiated Project (CSSIP) School Approval Form
The CSSIP credit option enables students who make a contribution to the community by volunteering for worthwhile
organizations or causes to receive recognition for the civic knowledge, skills, and attitudes obtained in the volunteer
activity. The volunteering done by students participating in the CSSIP is not the responsibility of the school, school
division, or Manitoba Education, but an opportunity made available to students to obtain credit for private activity.
STUDENTS SHOULD SUBMIT THIS FORM (INCLUDING THE ORGANIZATION’S CONTACT INFO/SIGNATURE), AND HAVE
VOLUNTEER PLACEMENT APPROVED BY THE SCHOOL BEFORE ANY VOLUNTEER HOURS CAN BE COUNTED FOR CREDIT.
Student Information (to be completed by Student)

Student Name: _____________________________________________________________________________________
School Attended: _Northlands Parkway Collegiate _________________________________________________________
School Address: _139 Northlands Parkway East, Winkler, MB, R6W 0E9_ Telephone: _204-325-8200__________
Student Telephone: _____________________ Student Email: ______________________________________________
STUDENTS ARE EXPECTED TO KEEP A DETAILED RECORD OF DAYS/HOURS VOLUNTEERED WITH ORGANIZATION. THIS
RECORD SHOULD BE SUBMITTED, ALONG WITH LETTER FROM ORGANIZATION, BEFORE CREDIT WILL BE GRANTED.
Anticipated Learning Outcomes (to be completed by Student)

Explain what you hope to learn/gain from the volunteer experience (civic knowledge, skills, attitudes):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Community Service Information (to be completed by Community Service Organization/Group)

IN ORDER FOR STUDENT TO EARN CREDIT, YOU ARE ASKED TO SUBMIT A LETTER CONFIRMING STUDENTS VOLUNTEER
SERVICE, AND HOW MANY HOURS WERE SERVED, AFTER STUDENT HAS COMPLETED HOURS REQUIRED FOR CREDIT.
NOTE: Full credit earned after 110 hours OR 0.5 for a minimum of 55 hours. A maximum of one (1) credit can be earned.
Students can continue with volunteer service after credit earned if they so choose.
Contact Person Name (please print): ____________________________________________________________________
Signature of Contact Person: _______________________________________ Date: ___________________________
Address of Organization: _____________________________________________________________________________
Telephone: ______________________ Email: ____________________________________________________________
Signatures (to be completed prior to hours used toward credit)

Student: _______________________________________________________ Date: ___________________________
Parent/Guardian: ________________________________________________ Date: ___________________________
School Contact: _________________________________________________ Date: ___________________________
--------------------------------------------------------------------------------------------
CREDIT APPROVAL (to be completed by school after volunteer service and hours confirmed with a letter received from
organization where volunteer hours were completed, along with student’s detailed record of days/hours served.)
Number of Hours Completed: __________ (note: minimum 55 hrs for 0.5 credit; 110 hrs for a maximum 1.0 credit)
Community Service Credit Value (circle one): 0.5 OR 1.0 Course Level (circle one): 11G 21G 31G 41G

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Community Service Student-Initiated Project (CSSIP) Parent/Guardian Approval Form

I have read and understand the above information.

Signature of Parent/Guardian Date

Signature of Student Date

Student Information (to be completed by Student)

School Attended: _Northlands Parkway Collegiate _________________________________________________________

Student Telephone: _ Student Email: __________________________

Anticipated Learning Outcomes (to be completed by Student)

Community Service Information (to be completed by Community Service Organization/Group)

Contact Person Name (please print): ____________________________________________________________________

Signature of Contact Person: _____________ Date: _

Address of Organization: _____________________________________________________________________________

Telephone: Email: ______________________________________

Signatures (to be completed prior to hours used toward credit)

Parent/Guardian: ______________________ Date: _

School Contact: _______________________ Date: _

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