YOUTH / ADULT AWARDS — VOLUNTEER SERVICE LOG (To be completed by Nominee)

YOUTH / ADULT AWARDS — VOLUNTEER SERVICE LOG (To be completed by Nominee)
Is this a NEW SUBMISSION or an ADDITION TO YOUR FIRST SUBMISSION?*

NEW SUBMISSION FOR VOLUNTEER LOGADDITIONAL SUBMISSION FOR VOLUNTEER LOG
Are you filling this out for Youth or Adult Nominee?*

YouthAdult
Name of Nominee*

First NameLast Name
Daytime Phone*
Please enter a valid phone number.
Email*

Confirmation EmailPlease use a valid email address.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Attending*
Current Grade*

9th Grade10th Grade11th Grade12th GradeOther
Please Specify*
Age

This volunteer service log MUST include community volunteer service performed in 2023; then list prior volunteer service in “PUTNAM COUNTY” within the last 4 years.*

	ORGANIZATION/AGENCY NAME	TYPE OF SERVICE PERFORMED	APPROXIMATE DATES OF SERVICE (Example: 1/2019 to 1/2023)	TOTAL # OF SERVICE HOURS	Contact Person, Address, & Phone Number
1
2
3
4
5
6
7
8

Additional Notes
Please Confirm that your Information is Accurate*

Yes itStill Need to Check
Should be Empty: