Rock County 4-H Community Service Recognition Form
This form is used to summarize the total hours worked on Community Service projects from October 1 through September 30th of the current 4-H year.
Club ________________________________________
TOTAL Number of hours worked on Community Service Projects for the year: ____________
(Add the number of hours worked from each Community Service Report Form
submitted to the UWEX Office.)
Annual recognition is based on the following criteria. Please check the appropriate level of recognition for your club, based on the total number of hours reported above.
_______ Bronze Certificate: 1- 10 total hours
_______ Silver Certificate: 11-20 total hours
_______ Gold Certificate: 21 or more total hours
If your club is selected for a special award, please list the club’s choice of agency/organization to receive a cash donation on behalf of the club:
4-H Club Chairperson________________________________________________________
Signature Date
Recognition forms are due to the UWEX Office by September 30th.