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Nursing Home Affidavit (CLF5)

Name  

School  

Circle yes or no as to whether or not the student helped at a nursing home for that week.

WeekDateCircle one
Week 1 Yes / No
Week 2 Yes / No
Week 3 Yes / No
Week 4 Yes / No
Week 5 Yes / No
Week 6 Yes / No
Week 7 Yes / No
Week 8 Yes / No
Week 9 Yes / No
Week 10 Yes / No
Week 11 Yes / No
Week 12 Yes / No
Week 13 Yes / No
Week 14 Yes / No
Week 15 Yes / No
Week 16 Yes / No
Week 17 Yes / No
Week 18 Yes / No
Week 19 Yes / No
Week 20 Yes / No
Week 21 Yes / No
Week 22 Yes / No
Week 23 Yes / No
Week 24 Yes / No
Week 25 Yes / No
Week 26 Yes / No
Week 27 Yes / No
Week 28 Yes / No
Week 29 Yes / No
Week 30 Yes / No
Week 31 Yes / No
Week 32 Yes / No
Week 33 Yes / No
Week 34 Yes / No
Week 35 Yes / No
Week 36 Yes / No
Week 37 Yes / No
Week 38 Yes / No
Week 39 Yes / No
Week 40 Yes / No
Week 41 Yes / No
Week 42 Yes / No
Week 43 Yes / No
Week 44 Yes / No
Week 45 Yes / No
Week 46 Yes / No
Week 47 Yes / No
Week 48 Yes / No
Week 49 Yes / No
Week 50 Yes / No
Week 51 Yes / No
Week 52 Yes / No

To the best of my knowledge, this is an accurate account of this student's attendance at his/her assigned nursing home.

     
Pastor's/school principal's signature   Date