Student Community Service Application Form

Please Fill In The Appropriate Information To Apply Online. All Fields Are Required To Be Filled In, Otherwise Application Will Not Be Processed. When Finished Please Click The Submit Application Button.

*denotes required field

STUDENT INFORMATION

*First Name *Last Name *Email Address
*Student ID *Contact Number *Academic Status

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ORGANIZATION INFORMATION
*Community Service Event *Date (month/day/year) *Start Time *End Time
:
:
*Contact Person First Name *Contact Person Last Name *Organization Name
*Address Apartment/Suite *City *State *Zip Code
*Phone Fax  
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ACTIVITY INFORMATION
*Volunteer Activity *Population If Children or Special Needs
*Has RSDM volunteered at this organization If yes, How long ago *Number of People Expected
*Materials supplied by your organization (e.g. tables, chairs, food, water, tablecloths):
*Approximately how many volunteers/faculty from RSDM will be needed for event:
SUPPLIES INFORMATION
Please select supplies needed from the following
Floss ea Bags-Large

ea

Toothpaste ea Coloring Books ea
Infant Toothbrushes ea Lecturing Materials
ea
Children Toothbrushes ea Large Puppet w/ Toothbrush ea
Adult Toothbrushes ea Large Teeth w/ Toothbrush ea
Bags-Small ea Other
Denture Kits ea  


Within 2 weeks, status of this application form will be e-mailed to you.