VISION 2013 VOLUNTARY SERVICE AWARD HOURS REPORTING FORM
http://www.gmwp.org/vsa/form.html
revised 5/21/2006 
Please return this form to: Brother Daniel Mata, 1414 Perimeter Drive, Jamestown, TN 38556.

Brother:  ___________________________________________________Bronze Award Date: __/__/__
Lodge:  _____________________________________________________Silver Award Date: __/__/__
                                                             Gold Award Date:   __/__/__

On the back of this form (or on attached sheets), please give details of dates, and hours
donated.  Use the form below to summarize hours worked in each activity.

COMMUNITY SERVICE:
     Habitat for Humanity                                                         ______
     Domestic Violence Shelter                                                    ______
     School Literacy                                                              ______
     VA Hospital Visitation                                                       ______
     Organ Donor Awareness                                                        ______
     Hospital Hospitality House                                                   ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______

YOUTH PROGRAMS:
     Youth Athletic Teams                                                         ______
     Boy and Girl Scout Leadership                                                ______
     4H Clubs                                                                     ______
     Rainbow, DeMolay                                                             ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______

ELDERLY ASSISTANCE:
     Lodge Widows                                                                 ______
     Tax, Medical Insurance Assistance                                            ______
     Fraternal Assistance                                                         ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______
     Other:  _________________________________________________________            ______

OTHER:
     _________________________________________________________________            ______
     _________________________________________________________________            ______
     _________________________________________________________________            ______

                                                                    Total Hours:  ______
                                                                    Prior Hours:  ______
                                                                   Accum. Hours:  ______


APPROVED:  ____________________________________________________________, Lodge Secretary

        or __________________________________________________________, Worshipful Master