Reference Form

YOUTH / ADULT AWARDS — REFERENCE FORM

Step 1 of 6

Please Enter Password*

Are you filling this out for a Youth or Adult Nominee*
- Youth
- Adult

Name of Nominee*
First Last

Name of Reference*
First Last
Daytime Phone*
Email*
Enter Email Confirm Email
Organization/Agency (If applicable)
Address*
Street Address Address Line 2 City State ZIP Code
Type / Name of Service this volunteer performed*

VOLUNTEER SERVICE VALIDATION/COMMITMENT
- List all volunteer work YOU DIRECTLY SUPERVISED that this nominee performed within the last 4 years; please list each position separately.
- If Nominee has been involved with your organization for multiple years, be sure to indicate the length of time & total # of hours below.
- This form CANNOT be completed by a parent or family member of the nominee, even if he/she is the leader of the group or organization.
ORGANIZATION/AGENCY SERVED (INCLUDE CONTACT PERSON & PHONE NUMBER) TYPE OF SERVICE PERFORMED BY THE NOMINEE APPROXIMATE DATES OF SERVICE (Example: 1/2015 to 1/2019) TOTAL # OF SERVICE HOURS
VOLUNTEER SERVICE VALIDATION/COMMITMENT
- List volunteer service you are personally familiar with. Service performed with youth in Putnam county in the last 4 years will be considered.
- If volunteer’s commitment is for multiple years, please detail: e.g. Boy Scouts-Monthly meetings-4 yrs. (2015-2019)
- If nominee served in various roles in the organization, be sure to list each position separately.
ORGANIZATION/AGENCY SERVED (INCLUDE CONTACT PERSON & PHONE NUMBER) TYPE OF SERVICE PERFORMED BY THE NOMINEE APPROXIMATE DATES OF SERVICE (Example: 1/2014 to 1/2018) TOTAL # OF SERVICE HOURS

EFFECTIVENESS: (Demonstrated by nominee's impact on individuals, organizations, and/or the community that he/she is working within):*
LEADERSHIP: (Demonstrated by how this nominee shows his / her innovation, initiative, and leadership skills in volunteer service efforts with individual youth, youth-serving organizations, and / or the community):*
INITIATIVE: (How the nominee demonstrated initiative in his/her volunteer efforts with individuals, organizations and/or community):*
ADDITIONAL NOTES / REMARKS:

Youth Award Nominee(s)/James F. Reitz Adult Award Nominee(s) must have “three” reference forms and a volunteer service log submitted on the Youth Bureau Website by or before Friday, January 29, 2021!

To be eligible for consideration, each Award Nominee must have a complete packet containing three completed online Reference Forms and one detailed Volunteer Service Log {to be completed by the award nominee}. Upon receipt of all forms, the nominee will be notified of his/her complete packet.

All sections of the online reference form must be completely filled in and submitted for the candidate to be considered.

Specific information must be provided regarding quality & quantity of volunteer work performed. Our Focus is Community Service that benefits Putnam Residents.

All complete packets will be reviewed, scored and ranked by the Youth Board Selection Committee. Those chosen to receive a 2021 Youth Volunteer Service Award will be honored at our Annual Youth Awards Dinner. (Due to the ongoing health crisis the date & location of the event is to be determined.)

Questions/inquiries:

Contact the Youth Bureau (845) 808-1600 Ext 46113 or youthawards@putnamcountyny.gov

Thank You for your Interest in the Youth of Putnam County!

Sponsored by the Putnam County Youth Bureau & Putnam County Youth Board 110 Old Route Six – Building 3 – Carmel, NY 10512 Phone (845) 808-1600 Ext. 46113

ORGANIZATION/AGENCY SERVED (INCLUDE CONTACT PERSON & PHONE NUMBER)	TYPE OF SERVICE PERFORMED BY THE NOMINEE	APPROXIMATE DATES OF SERVICE (Example: 1/2015 to 1/2019)	TOTAL # OF SERVICE HOURS

ORGANIZATION/AGENCY SERVED (INCLUDE CONTACT PERSON & PHONE NUMBER)	TYPE OF SERVICE PERFORMED BY THE NOMINEE	APPROXIMATE DATES OF SERVICE (Example: 1/2014 to 1/2018)	TOTAL # OF SERVICE HOURS

YOUTH / ADULT AWARDS — REFERENCE FORM

Step 1 of 6

VOLUNTEER SERVICE VALIDATION/COMMITMENT

VOLUNTEER SERVICE VALIDATION/COMMITMENT

Youth Award Nominee(s)/James F. Reitz Adult Award Nominee(s) must have “three” reference forms and a volunteer service log submitted on the Youth Bureau Website by or before Friday, January 29, 2021!