COMMUNITY SERVICE REFERENCE FORM
TO THE SUPERVISOR:
We thank you for your participation in our community service program. Poly Prep recognizes and values the time and
effort you have given in making this student’s experience with your organization possible. Your frank review of this
student and of the experience will be kept confidential.
PART I:
(TO BE COMPLETED BY THE STUDENT)
Present this form, together with your time sheet to your direct supervisor when you have completed your service
experience. The form may be emailed to esivin@polyprep.org, dcatharine@polyprep.org, faxed to Poly Prep at
718.630.5443 or mailed to:
Directors of Community Service
Dana Catharine or N. Elijah Sivin
Poly Prep Country Day School
9216 7th Avenue, Brooklyn, NY 11228
If your supervisor wishes to mail the form, please provide them with a stamped, addressed envelope.
STUDENT NAME (please print) : ______________________________________________________________________
FORM/GRADE: ________ DATES OF SERVICE: ________________________________________________________
NAME OF NON-PROFIT ORGANIZATION: ____________________________________________________________
SUPERVISOR NAME (please print):___________________________________________________________________
SUPERVISOR PHONE # ___________________________ SUPERVISOR EMAIL ________________________________
WEBSITE OF ORGANIZATION_________________________________________________________________________
PART II: (TO BE COMPLETED BY THE SUPERVISOR)
Please use the following questions to characterize the student’s work as compared to others of his or her age.
1. What was the quality of the student’s volunteer service?
Poor ______ Indifferent ______ Average ______ Good ______ Outstanding______
2. What was the quantity of their experience?
Just met requirements (40 hours for Poly) ______ Above requirements ______ Well above requirements ______
3. Did the student assume responsibility in an acceptable way?
No ______ OK with significant supervision ______ Reasonably reliable ______
Worked independently ______ Displayed positive initiative______
4. Did the student display good judgment?
No ______ Displayed poor judgment ______ Reasonable judgment ______
Good judgment ______ Very mature judgment ______
5. Was the student cooperative?
No ______ Limited ______ Reasonably cooperative ______
Good team worker ______ Very helpful and cooperative ______
6. Did the student report to the site promptly or inform clearly advance if unable to do so?
No ______ Only a little late on occasion ______ Generally prompt ______ Always prompt ______
Other comments about the student:
Other comments about our Community Service Program:
Date ___________
Thank you!
Supervisor’s Signature: ________________________________