YOUTH / ADULT AWARDS — VOLUNTEER SERVICE LOG (To be completed by Nominee/Nominator for Adult)
Is this a NEW SUBMISSION or an ADDITION TO YOUR FIRST SUBMISSION?
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NEW SUBMISSION FOR VOLUNTEER LOG
ADDITIONAL SUBMISSION FOR VOLUNTEER LOG
Are you filling this out for Youth or Adult Nominee?
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Youth
Adult
What is your email?
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Confirmation Email
Please use a valid email address.
Name of Nominee
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First Name
Last Name
Daytime Phone
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Please enter a valid phone number.
What is the Nominee's email?
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Attending
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Current Grade
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9th Grade
10th Grade
11th Grade
12th Grade
Other
Age
This volunteer service log MUST include community volunteer service performed in 2024; then list prior volunteer service in “PUTNAM COUNTY” as well as any volunteer service in the surrounding counties within the last 4 years.
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ORGANIZATION/AGENCY NAME
TYPE OF SERVICE PERFORMED
APPROXIMATE DATES OF SERVICE (Example: 1/2020 to 1/2024
TOTAL # OF SERVICE HOURS
Contact Person, Address, & Phone Number
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2
3
4
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6
7
8
Why do you feel that you / the person you are nominating are deserving of this award?
0/1000
Additional Notes
Please Confirm that your Information is Accurate
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Yes it
Still Need to Check
Submit
Should be Empty: