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 LOG
ADDITIONAL SUBMISSION FOR VOLUNTEER LOG
Are you filling this out for Youth or Adult Nominee?
*
Youth
Adult
Name of Nominee
*
First Name
Last Name
Daytime Phone
*
Please enter a valid phone number.
Email
*
Confirmation Email
Please use a valid email address.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Attending
*
Current Grade
*
9th Grade
10th Grade
11th Grade
12th Grade
Other
Age
Please Specify
This volunteer service log MUST include community volunteer service performed in 2022; 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: 1/2018 to 1/2022)
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 it
Still Need to Check
Submit
Should be Empty: