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
	( ) -

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
( ) -	( ) -

ACTIVITY INFORMATION

*Volunteer Activity	*Population	If Children or Special Needs

*Has NJDS 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 NJDS 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.