Event Registration
Please complete the following form or download the PDF to submit by mail. Contact Kathy Sims with any questions (ksims@middlebury.edu or 802-443-5652).
Organizer/Organization Information
Name of School (if applicable):
Name of Organization:
Name of Organizer (main contact):
Title:
Address:
City: State: Zip:
Phone:
Fax:
Email (required):
Project Information
Event Name:
Focus of Project:
Poverty, Hunger and Homelessness Education and Youth Development Civil Rights Equality and Empowerment Physical and Emotional Health Environment and Climate Change Global Citizenship and Cooperation Sustainable Community Development Public Safety, Crime and Violence Disaster Prevention and Relief Immigrant/Refugee Assistance Senior Citizens Civic Engagement
This project will consist of the following elements:
Service Advocacy Public Speakers Reflection Celebration Awareness/Education Philanthropy Other (specify)
Please give a one paragraph summary of the planned project or event:
Day-of information (such as what to bring/what to wear):
Number of volunteers that will participate (anticipated): Please Select... 0-10 10-20 20-30 30-40 40-50 50 or more
Would you like VCC to advertise this event as open to other volunteers? Please Select... Yes No
Date of service: January February March April May June July August September October November December 2010 2011 2012
Start Time: : AM PM
End Time: : AM PM
Location name of service site:
Street address of service site:
City, State, Zip Code of service site:
Latitude and Longitude of service site (if known):
County of service site (required): Please select... Addison Bennington Caledonia Chittenden Essex Franklin Grand Isle Lamoille Orange Orleans Rutland Washington Windham Windsor
Check any of the GYSD Grantees you are affiliated with:
State Farm Good Neighbor Service-Learning Grant Winner US Lead Agency Youth at the Center Disney Minnie Grant Winner United Healthcare Group grant winner Semester of Service Grant winner Red, White, and Green Grant Winner J-Serve Grant Winner NEA-YSA Youth Leaders for Literacy Winner Service for Peace Grant Winner
Please indicate which Service Events, not including GYSD, your school or organization participates in:
MLK Day of Service Semester of Service Earth Day World Malaria Day Days of Interfaith Youth Service March for Babies Day National Environmental Education Week National Wildlife Week J-Serve Read Across America SAE’s True Gentleman’s Day of Service Student Leadership Week
For security purposes, enter the following number exactly as you see it:
Vermont Campus Compact :: 152 Maple Street, Suite G-01, Middlebury, VT 05753 :: (802) 443-2506