State CounCil ServiCe Program awardS entry Form

1 THIS REPORTING form MUST BE COMPLETED BY EACH CounCil AND FORWARDED TO THE State CounCil .(A separate reporting form should be completed for each Program category.)Page 1 of 2 continued on reverse Category (mark one): Faith Family Community liFeCOUNCIL INFORMATION: CounCil numBer: _____ total CounCil memBerS: _____grand knight: _____ e-mail: _____PROJECT INFORMATION /complete all sections0:ProjeCt title: _____ ProjeCt date: _____Participation:_____ + _____ = _____ _____ x _____ = _____ Members Non Members Total Participants Total Participants Hours Total Volunteer HoursProgram Planning:_____ & _____ members recruited:_____ donations:_____ Costs Time Local Currencydescribe project in detail.

2 Use additional paper if necessary. Supplementary material may be submitted along with the nomination. accompanyingmaterials can include letters, testimonials, news clippings, photographs, pamphlets, etc. do not submit tapes, videocassettes, dvd s, displaymaterials, films, etc., as they will not be considered in judging the ) in the space provided below, briefly describe the purpose and goals of this Program . This section must be NOT SUBMIT THIS REPORT form TO SUPREME COUNCILENTRY MUST BE RECEIVED BY THE State COUNCILTO BE ELIGIBLE FOR THE COMPETITION mail original to: State Deputy or State Program DirectorCoPy to: CounCil FileAvailable in electronic format at 11/18 Page 2 of 23b) whom does this project benefit? 3c) what problem or need did this project resolve?3d) why did the CounCil select this project?3e) describe the success of the project:Attest: _____ State Deputy Signed: _____ _____ Grand Knight Dat