John Carroll University - Center for Service and Social Action

ABOUT US STUDENTS FACULTY COMMUNITY PARTNERS JCU STAFF ALUMNI EVENTS & PROGRAMS

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The following information will be used by the Center of Community Service and Social Action to best determine your placement for service and to keep you informed of service opportunities or events. (Non-identifying information may also be used for program development and assessment purposes.) Kindly fill in the form as completely as possible.

General Information
All Required (*)
Banner ID	*
Last Name *	First Name *	Middle Initial
JCU / Local Address
Box No. / Street	Phone
*	*
City	State	Zip
*	*	*
Permanent Address
Box No. / Street	Phone
*	*
City	State	Zip
*	*	*
Email Address *

Participant Background Information

Participant Status Required

Your academic major
Check here if undecided.

Anticipated Year of Graduation Required if student

20092010201120122013201420152016201720182019

Gender

Male Female

What category best describes your racial ethnic origin?


African American (non-Hispanic)	Hispanic/Latino/a	Asian/Pacific Islander
Multi-racial	European American	Native American / Alaskan Native
Prefer not to respond

Date of Birth mm/dd/yyyy

How did you hear about The Center for Service and Social Action?


Instructor/advisor	Flier/Poster/Advertisement	Classmate
Alumni Office	Parent/alumnus/a	Email
Student Organization member	Website

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John Carroll University, University Heights, OH 44118 | (216) 397-4294 | (888) 335-6800 (toll-free) | (216) 397-4981 (fax)