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Please fill out this form and attach it to a letter of
support as it relates to the selection criteria below Individual
Adult/Youth/Group Nominee/s (circle one) Name: First
Last
Phone
Address
City/State/Zip
Name and
Address of Volunteer Organization
_____________________________________________________ __________________________________________________________________________________________ Length of
nominee’s volunteer service with the organization_________ Total average
nominee’s volunteer hours per month
Address
______________________________________ City/State/Zip
________________________ Signature Date Letter
of support: On a separate sheet, please provide a letter of support as it
relates to the selection criteria Need:
Nominee contributed a needed service to community.
Action:
Involvement of the nominee was voluntary or above and beyond..
Initiative:
Nominee initiated new programs or activities and used new methods
to solve problems.
Achievement:
Nominee made a difference in the community.
Impact: The activity or service produced positive changes and provided examples for other groups. Time: Amount of time (that was not required) devoted to the activity or service was significant
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