300 Dalmeny Road
Briarcliff Manor, NY 10510
Ph# 914-762-1050
www.sttheresa.net
First Name______________________Last Name_________________________________________
Address_________________________________________________________________________
Phone number____________________e-mail____________________________________________
Grade_________________Teacher______________________age___________________________
Please list all organizations and groups that you will be tracking service hours for.
(example – scouts, alter server, choir, coaching, volunteering at church/school)
1. _____________________________________________________________________________
2. _____________________________________________________________________________
3. _____________________________________________________________________________
4. _____________________________________________________________________________
5. _____________________________________________________________________________
6. _____________________________________________________________________________
Service hours will be collected on a monthly basis.
Log sheets are available on the school website.
Please see www.presidentialserviceawards.gov for further infomation.