Work of Heart Awards

Nominee

Name (Individual or Group)
Contact Person (If Group)
Address
Years of Volunteer Service
Total Hours Volunteered Last Year

Nominee Phone #
Email
City
State/Zip
If Group, # of Volunteers

Volunteer Site Information

Agency Served
Address
Volunteer Coordinator
Phone #

City
State/Zip
Website
Email

Nominator

Name
Agency/Business
Address
Signature

Email
City
State/Zip
Date Submitted

Activity - Briefly describe the nominee's volunteer services.

Impact on the Community - Describe the impact or difference the nominee's service made
on the community. Be specific.

Time - Approximately how much time has the volunteer dedicated to the activities outlined above? How long has the volunteer been engaged in these activities.