NOMINATION FOR NATIONAL SERVICE RECOGNITION AWARD
Board Member / Other Volunteer
(Please type or print name as desired on certificate)
DATE AWARD IS TO BE PRESENTED:
Nomination for (please check award desired):
National Service to Youth Award Certificate, Medal, and service pin for
years of service ($20 each)
Certificate and national service pin (only) for years of service ($10 each)
National (Boys & Girls Club) Medallion ($20 each) (Please completed “Addendum A”)
National Silver Medallion ($20 each) (Please completed “Addendum A”)
The Jeremiah Milbank Gold Medallion (No charge)
National Award of Merit (No charge)
Mailing address to send award:
City: State: Zip:
BOYS & GIRLS CLUB SERVICE RECORD
List the dates (at least month and year) of service the nominee has served on a board of directors or other volunteer
organization of a Boys & Girls Club and/or Boys & Girls Clubs of America. Continue on additional page, if necessary.
Name of Club of Service From To
COMMITTEE MEMBERSHIP/OFFICES HELD
List committees on which nominee has served and any offices held. Show dates (at least month and year) of service on each
committee. Include dates and titles of offices held.
Dates of Dates in
Committee Membership Office(s) Held Office
SERVICE TO THE BOYS & GIRLS CLUB AND TO THE MOVEMENT (REQ’D)
List below information about the nominee’s voluntary service (such as service on an alumni association, other ancillary
groups, etc.) and one or two specific contributions to the Boys & Girls Club. List other local, regional or national
committees/task groups on which the nominee has served and other positions held in the Boys & Girls Club Movement.
Provide dates of service (at least month and year), if known. Include service such as Area Council liaison, Area Council
chair, membership on planning task groups, etc.
EDUCATION, SERVICE TO THE COMMUNITY AND OTHER AFFILIATIONS (AT LEAST ONE-REQ’D)
List below nominee’s educational background, membership in professional and civic organizations and honors and awards
received in and outside the Boys & Girls Club Movement. Include any other details that may be included in remarks to be
made by the person who will be presenting the award. Attach an additional sheet, if needed.
FOR NATIONAL AWARD OF MERIT ONLY (any “non-BGC” individual who provides outstanding service to BGCs)
Please write personalized wording for certificate.
Additional comments regarding this nomination processing:
BOYS & GIRLS CLUBS OF AMERICA RECORD - DO NOT WRITE HERE
Date Received in Regional Service Center______________________________________________________________________
Date Acted Upon ____________ Requested Award Approved ________________ Not Approved________________________
Date of Presentation Recorded in Data Base __________________________________ by_______________________________
Date Award(s) mailed to club from Regional Office: _______________________________________
ADDITIONAL INFORMATION REQUIRED FOR NATIONAL MEDALLIONS
In order to be eligible for a National Medallion, board members and other organization volunteers must meet criteria as
outlined in the National Service Recognition Program Tool Kit. To assist the Awards Committee in recognizing deserving
individuals with National Medallions, please provide specific information about the candidate’s service in the areas listed
Fund-raising, personal giving and campaign leadership (detailed information including specific amounts given and/or
( THIS FIELD WILL EXPAND WITH TYPING )
Promotion Leadership (leadership in founding a new Boys & Girls Club(s) and/or providing service to additional youth)
Promotion and marketing of the organization and/or the Boys & Girls Club Movement (service as a
“spokesperson” and/or goodwill ambassador in and outside the community)
Leading a major project of community, state, regional or national significance
Other evidence of candidate’s impact on meeting the needs of children in the Boys & Girls Club Movement.