UCO: Topic - Volunteer and Service Learning Center - A Division of Student Affairs at the University of Central Oklahoma

Division of Student Affairs
Volunteer and Service Learning Center
Alternative Spring Break Application

Volunteer and Service Learning
2012-2013 Events Calendar
The Big Event
Central Pantry
Alternative Break Programs
Distinguished Service Graduate
Service Hours/Transcript
Scholarship and Grants
Volunteer Activities Council
Service Learning
FAQs
Student Life
Student Affairs
Contact Us
Weekly E-BLAST


*First Name:

*Last Name:

*Classification:

*Banner ID:

*Cell Phone:

*Mailing Address:

*City:

*State:

*Zip:

*Email address you check:

*Please list any allergies:

*Please list any major medical conditions:

*Have you been vaccinated for tetanus in the last 10 years?:		Yes No

*Please list any medications (prescription/OTC) that you take regularly:
You will be required to provide documentation showing proof of health insurance. We will need to make a copy of your insurance.
*Health Insurance Provider:

*Policy Number:

*Policy Dates:

*Provider Mailing Address:

*City:

*State:

*Zip:

*Provider Phone:
Please provide the following information about your emergency contacts:
*Contact Name:

*Mailing Address:

*City, State, Zip:

*Daytime Phone:

*Evening Phone:

*Relationship:

*Contact Name:

*Mailing Address:

*City, State, Zip:

*Daytime Phone:

*Evening Phone:

*Relationship:
Special Skills Please indicate if you have experience in any of the following areas or can speak and of these languages.
*Special Skills:		Construction Electrical Plumbing Landscaping/Dirt Work Debris Clean-Up Demolition Carpentry Mucking Out Making Care Packages Meal Preparation Arabic Cantonese French Haitian Creole Hindi Spanish Italian Korean Russian Polish Mandarin Yiddish

*Other Skills:

*Have you participated in an Alternative Break trip before at UCO?:		Yes No
In 150 words or so per question, please answer the following questions.
*Why do you want to participate in Alternative Spring Break?:

*What does service mean to you?:

*What are you passionate about?:

*When working in a group, what do you add or how do you encourage others?:

University of Central Oklahoma

Volunteer and Service Learning Center

Alternative Sping Break, March 17-23, 2013
Superstorm Sandy Relief
Gerritsen Beach/Far Rock Away, NY

Application due by 5p.m., Friday, February 8, 2013

A Department of Student Affairs

University of Central Oklahoma

Volunteer and Service Learning Center

Alternative Sping Break, March 17-23, 2013 Superstorm Sandy Relief Gerritsen Beach/Far Rock Away, NY

Application due by 5p.m., Friday, February 8, 2013

A Department of Student Affairs

Alternative Sping Break, March 17-23, 2013
Superstorm Sandy Relief
Gerritsen Beach/Far Rock Away, NY