Youth / Adult Award - Reference Form
Are you filling this out for a Youth or Adult Nominee
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Youth
Adult
Name of Nominee
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First Name
Last Name
Name of Reference
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First Name
Last Name
Reference Daytime Phone
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Please enter a valid phone number.
Reference Email
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Confirmation Email
Please use a valid email address.
Organization/Agency (If applicable)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type / Name of Service this volunteer performed
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VOLUNTEER SERVICE VALIDATION/COMMITMENT
List all volunteer work YOU DIRECTLY SUPERVISED that this nominee performed within the last 4 years; please list each position separately. If Nominee has been involved with your organization for multiple years, be sure to indicate the length of time & total # of hours below. This form CANNOT be completed by a parent or family member of the nominee, even if they are the leader of the group or organization.
PLEASE PUT IN THE DATE AND TOTAL HOURS
ORGANIZATION/AGENCY SERVED (INCLUDE CONTACT PERSON & PHONE NUMBER)
TYPE OF SERVICE PERFORMED BY THE NOMINEE
APPROXIMATE DATES OF SERVICE (Example: 1/2020 to 1/2024)
TOTAL # OF SERVICE HOURS
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DEDICATION: (Demonstrated by consistent and reliable involvement with individuals, organizations, and/or the community):
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Please describe this nominee’s dedication towards the service they are taking part in:
EFFECTIVENESS: (Demonstrated by nominee's impact on individuals, organizations, and/or the community that they serve.):
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Please describe this nominee’s effectiveness towards the service they are taking part in:
LEADERSHIP: (Demonstrated by how this nominee shows their innovation, initiative, and leadership skills while performing volunteer service efforts.):
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Please describe how this nominee has demonstrated leadership:
ADDITIONAL INFORMATION that may be of value about this nominee:
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