C Family and Group Certification Form

PRESIDENT'S VOLUNTEER SERVICE AWARDS FORM C
FAMILY AWARD CERTIFICATION FORM
A separate form should be completed for each family receiving the President's Volunteer
Service Award. Please type or print using blue or black ink. Photocopy this form as

to use

needed. The Award Order Form and payment should accompany this form.
Please fax completed forms to 1-202-729-8033.

Family/Group Information
CONTACT NAME
STREET ADDRESS
CITY
PHONE
(
)
Family/Group name preferred on certificate

ZIP

STATE
EMAIL

Family/Group Volunteer Information
How many members are in the family/group? __________
How many hours did the family/group complete during the 12-month period? __________
Where did the family/group perform most of their volunteer service? ____________________ U.S. state or country
Service Classification (Check the box in which most of the volunteer activity took place.)
Youth Achievement
Includes volunteer activities such as mentoring, coaching, tutoring, improving literacy in areas such as reading and
finance, and volunteering to keep young people engaged academically in education.
Parks and Open Spaces
Includes volunteer efforts to conserve and protect our parklands and gardens, neighborhood cleanups and creating safe
playgrounds. It also includes creating safe and meaningful experiences and outdoor activities for individuals to enjoy
the environment and our natural resources.
Healthy Communities
Includes volunteer efforts to help the elderly, disabled, diseased, hungry or homeless, and to improve the economic health
of the community. These could include volunteering for health and nutrition education services, immunization campaigns,
resume building, career training, disease screenings, hospital support, blood drives, veterans outreach, working with
local public health programs, micro-enterprise and business development.
Public Safety & Emergency Response
Includes volunteer efforts for individuals and families to make their homes, and their communities safer from the threats of
crime, terrorism, and disasters of all kinds. It includes preparedness training, volunteer firefighters, and programs
like Citizen Corps, Neighborhood Watch, Medical Reserve Corps and Volunteers in Police Service.
Global Health & Prosperity
Includes international volunteer efforts by American professional serving abroad through non-governmental organizations
and companies to share their skills in the following areas: agriculture, capacity building, economic growth, education,
HIV/AIDS prevention and treatment, health care, information technology, natural resources, clean water, women
& youth empowerment.

Tell us more about the award recipient's service. (35 words or fewer)

Demographic Information (this section is optional)
Gender
Female
Male
Age
_____5-14 _____15-21 _____22-35 _____36-49

Ethnicity: Hispanic or Latino? _____ yes _____ no
Race Please mark one or more
Alaska Native/ American Indian
Asian
Education (Highest level completed)

(Optional)

_____50+

If "yes" please indicate how many. ________

Black / African American
Native Hawaiian or Pacific Islander

White

K-8

High School or GED

Undergraduate Degree

9-11

Some College

Graduate/Professional Degree

I hereby certify that my organization has verified that each individual or group specified on this form has met the respective
criteria necessary to earn the President's Volunteer Service Award and completed the volunteer activities in at least one of the
four Volunteer Service Action Priorities.

Signature
Name of organization
See reverse for Public Burden Statement and Privacy Act Notice.

DATE

OMB Control #: 3045-0086
Expiration Date: 02/28/2007

Public Burden Statement: The public burden for this collection of information is estimated to
average 20 minutes per submission, including reviewing instructions, gathering the data needed,
and completing the form. Comments on the burden or content of this instrument may be sent to
the Corporation for National and Community Service, Office Public Affairs, 8th Floor, Attn:
Ms. Rhonda Taylor, 1201 New York Avenue, N.W., Washington, D.C., 20525. The
Corporation informs people who may respond to this collection of information that they are not
required to respond to the collection of information unless the OMB control number and
expiration date displayed are current and valid. (See 5 C.F.R.1320.5(b)(2)(i)).
Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice
be provided to you. The authority for collecting this information is contained in Executive
Order 13285, signed January 29, 2003. The principle purpose for collecting this information is
to recognize individuals, schools and organizations that excel in their efforts to support
volunteer service and civic participation, especially with respect to students in primary and
secondary schools, and institutions of higher learning. The information will be used to select
winners of the President’s Volunteer Service Awards and the Call to Service Awards.
Nominations for these awards are voluntary. All information that is provided to the Corporation
and its administrating organization will not otherwise be disclosed to entities outside of the
Corporation without the approval of the individual or organization nominated for the award.

Instructions for FORM C (Family Award Certification Form)
All President’s Volunteer Service Awards must be verified and issued through institutions which
we call Certifying Organizations (CO). If the nominee is an individual, family, or group who is
seeking the PVSA and are associated with any organization such as a faith-based institution,
school, higher education, nonprofit and community based organization, business, labor union,
civic or service club, membership and trade association, and federal, state or local government
agency, please ask for one of these to become a CO and verify your service.
There is a nominal charge for the recognition packet. Some organizations may cover the cost of
the packet. If the CO is unable to cover this cost, it is appropriate for the individual volunteer, if
asked, to help cover the cost.
To earn an award, individuals, families and groups must keep a record of volunteer activities and
hours served. This record of service may be kept as a diary or calendar or tracked online with the
USA Freedom Corps Record of Service available on the President’s Volunteer Service Award
site at www.presidentialserviceawards.gov.
For the purpose of the President’s Volunteer Service Award, a family is any self-designated
group of two or more individuals who considers themselves a family. Each member of the
family must complete at least 25 hours of service with a family’s cumulative hours being at least
200 hours in the 12-month period.
Family Information:
Please fill out the information for the family. The contact name should be the name of the family
member who can be identified as a contact person.
Volunteer Information: Please answer all questions.
How many hours did the family complete during the 12-month period? Please fill in number of
hours. The 12-month period does not depend on a calendar year, school year, or any other time
period other than the 12-month period preceding the application for the PVSA.
Where did the family perform the majority of their volunteer service? Please fill in the blank
with the location whether a U.S. state or other country, where the volunteers performed the
majority of service. Service can be in many locations, so please just indicate where the majority
of service took place.
Primary Service Area:
Descriptive information under each category provides examples of appropriate activities. This is
meant to be descriptive rather than exclusive and describes some specific activities that would
qualify.
Optional Information:
For each category, please fill in the total number that would fit into each group.
Gender: Enter number of females and number of males in the group.
Age: Please indicate the age of individuals at the completion of service hours by reporting the
number of individuals who are in each category.
Ethnicity: Does the individual consider himself or herself Hispanic or Latino? Please indicate the
number of individuals who would answer "yes", and the number of individuals who would
answer "no".
Race: Please mark all that apply.
Education: Please indicate the highest level of education completed for each individual by
reporting the number of individuals who are in the each category.