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Sponsor of the event:
List all necessary.
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What is your affiliation?
If you checked Student Organization, please list the name of the organization below.
Student Organization
Individual
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Student Organization name:
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Your Name:
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Email:
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Phone:
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Non-profit organization benefiting from service:
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Agency Contact Name:
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Date service was completed:
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Total contribution:
For example, pints of blood, pounds of food, money, hours. List all applicable.
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Brief description of service, project or contribution:
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