Community Health Outreach Summary Form


Community Health Outreach Summary Form

Please Fill In The Appropriate Information. When Finished Please Click The Submit 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
:
*Location (City/State)   *End Time
  :
ACTIVITY INFORMATION
Age Range (count) Ethnicity (percentage)  
12 and under White
13-17 Black
18-64 Hispanic
65+ Asian/Pacific Islander
    Other
Patients with Special Needs (as many as applicable):    
Developmental disabilities  
Cognitive impairment  
Complex medical problems  
Significant physical limitations  
Vulnerable elderly  

*Supplies provided (type, amount)
Additional Information