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PVSA service recording form - PLAY Leadership
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Name*:
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Address:
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Birth Date*:
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Age Group:
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Email*:
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Award Year:
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Volunteer Activity Name
Date of Activity
Activity DescriptionHoursPlaceFocus AreaSignature of Event
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Total Hours
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I __________________________ (parent) hereby acknowledge that my child _________________________ (applicant)
is a citizen or a lawfully admitted permanent residents of the United States. The service hours applied for this PVSA
application is not paid and is not court-ordered.
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Date: _________________________
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Signature: _______________________
(Parent)
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Signature: _______________________
(Applicant)
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