This form is for active volunteers or interns who are in a reoccurring placement. Please submit monthly activity logs by the first Monday of each month using this form. If you have questions, please contact us at volunteers@depelchin.org.

First Name:		Last Name:
Telephone:		Email:
Placement Title:	--Please Select One--Administrative VolunteerAdoption Kids Group VolunteerART Monday Night VolunteerArtBridgeBoardDonation StationHoliday ProjectInternMentorOne Time Group VolunteerPlayroomReading NookSatellite Hospitality VolunteerSpeakers BureauSpecial Projects VolunteerStory TimeTuesday Book ClubTutorVolunteer Council MeetingWednesday Art VolunteerWednesday Foster Care Playday	Supervisor:
Department:	--Please Select One--AdoptionCounselingDevelopment/AdvancementElkins Residential Treatment CenterFoster CarePost AdoptPreventionRecords ManagementRGMRichmond Residential Treatment CenterTraining/HR

Date (M/D/Year):	Volunteer Activity or Placement:	Number of Hours: