Volunteer Services Application

This form is used for Mr. & Miss Juneteenth participants to document and verify their community service hours. All volunteer hours must be verified and supported with photos and a contact reference.

1- Student Information

Full Name *

Student Phone Number *

Student Email *

Program Title *

School Name *

Grade Level *

Parent or Guardian Full Name *

Parent/Guardian Phone *

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others. from Juneteenth NY at the phone number provided. Frequency may vary. reply STOP to opt out.

2- Volunteer Activity Details

Name of Organization / Event You Volunteered With *

Who Did You Serve? *

Description of the Volunteer Work Completed *

3- Hours Verification

Date of Service *

Start and End Time (i.e. 9:00 AM to 1:00 PM) *

Total Hours Completed *

4- Volunteer Supervisor Verification

We must be able to verify your service hours.

Supervisor / Contact Person Name *

Supervisor Title / Role *

Supervisor Phone Number *

Supervisor Email *

5- Photo Evidence (Required)

To verify participation, photos must be submitted.

Upload Photos From Your Volunteer Service (file upload)

Requirements:

At least 1–3 photos Must clearly show you participating in the activity

6- Reflection (Leadership Component)

What did you learn from this volunteer experience?

How did this service impact the community you served?

How does this experience connect to the mission of Juneteenth (freedom, service, and community empowerment)?

Confirmation *

I confirm that the volunteer service hours submitted above are accurate and can be verified by the contact listed.

I understand that hours may not be counted if verification cannot be confirmed.