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
:
*Number of People Screened   *End Time
  :
ACTIVITY INFORMATION
Age Range (Percentage) Ethnicity (percentage)  
Under 5 White
6 - 18 Black
18 - 60 Hispanic
60+ Asian/Pacific Islander
Number of Volunteers:   Other
Students Number of person with unmet needs (approximate, if know):
Faculty
Staff  
Community  

*Supplies provided (type, amount)
Were pictures taken?
*Name of volunteers