Project Community Registration Form

This form was last changed on February 8, 2013

Club/Org Information

Club/Organization Name: *

Member Name: *

Member Email: * @psu.edu

Member Phone Number: *

Community Service Begin Date: *

Community Service End Date: *

What agency will you be working with?: *

Primary duties (Please specify): *

Location where service project will take place (be specific): *

Agency Contact Information

Individual's Name: *

Email Address: *

Phone Number: *

Address of Agency: *

More to say about your project?