Student-Athletes Community Service Program

Required Fields are in Bold

Organization Information
Name of Organization
Street Address
ZIP Code
Please categorize your organization as one of the following:
Registered Non-Profit
Educational Institution
If applicable, please enter your 501(c)3 Not-for-Profit number.
Contact Information
Contact Name
Daytime Phone
Cell Phone
Email Address
Event Information
Name of Event
Date of Appearance/Event
Location of Appearance/Event
Appearance/Event Address
Appearance/Event Location City
Appearance/Event Location ZIP Code
Appearance/Event Major Crossroad (Street 1)
Appearance/Event Major Crossroad (Street 2)
Name of Contact Person on-site at Appearance/Event
Cell Phone for Contact Person on-site (in case of emergency)
Time of Event (time the event starts)
Time of Speaking/Appearance (Time you would like the speaker to start)
Length of Presentation (i.e. 30 minutes)
Type of Appearance/Event
If you selected "Other" for event type, please describe event
Will this event be advertised? If yes, please list the target population and means of marketing the event.
Topic of Presentation (Please describe EXACTLY what you would like the speaker to do and/or the speaking topic)
Age Range of People Benefiting (i.e. 5-60 years)
Number of People Attending
Number of Minorities Benefiting (This figure helps us determine minority outreach efforts)
Gender Breakdown of those Attending (by number)
Other Comments