Your Name:

Your Email:

Please complete this form and submit with pictures (add below) no later than June 3.

CONTACT INFORMATION

Lodge Name *

Contact Person *

Address *

Street Address

City

Zip / Postal Code

Area Code

Phone Number

Email *

PARTICIPATING ORGANIZATION

Name of organization with which you joined hands *

Is it a youth organization? *

•   Yes
•   No

VOLUNTEERS

How many volunteers took part in the project? *

PROJECT SCHEDULE AND LOCATION

Date and time of project *

Project Location *

Address *

Street Address

City

Zip / Postal Code

DESCRIBE YOUR PROJECT *

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