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Organization Name
*
Campus Affiliation
*
- Select -
Student Club
Academic Department
Other Department
Other (please specify)
*
Contact Name
*
Please include first and last names for the main point-of-contact.
Contact Email
*
Contact Telephone
*
Contact Telephone, part 1
-
Contact Telephone, part 2
-
Contact Telephone, part 3
ext.
Contact Telephone, part 4
Project Goals and/or Outcomes
*
Estimated Number of Hours Contributing to Direct Service
*
Calculate total number of hours, e.g., 30 minutes x 20 students = 10 hours.
Expected Number of Total Participants
*
Expected Number of Student Participants
*
Expected Project Date
*
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Additional Comments
Is there anything else you'd like to add or any specific questions
Submit