Community Service Registration

The form will be submitted to the office of risk management who will develop and email a waiver to you that all participants need to complete prior to your service. A staff member will contact you directly if additional information is needed regarding your service plans.

This form will also be submitted to the Sturzl Center for Community Service and Learning. The Sturzl Center staff can provide additional resources for preparation and reflection if desired. You may receive an email back from your Sturzl Center liaison sharing additional resources that might be helpful in your service experience.

Registration Form
*First name:
*Last name:
*Email address:

Status at St. Norbert College (choose one):
*Faculty
If faculty, please answer the following questions:
Course name
Course number
Is the service a required or optional component of the course?	Yes No
*Staff
If staff, please answer the following questions:
Department:
Name of service program:
*Student – Service as part of an academic course
If a student participating in service as part of an academic course, please answer the following questions:
Course name:
Course number:
Course instructor:
*Student – Service project for a student organization or student group
If a student participating in service for a student organization or group, please answer the following questions:
Organization name:
Advisor:
Advisor email:
Service Information
One time service event/program On-going service
Date you will be serving:
Provide a brief description of the service activity:
Share any risks you are aware of:
Is this a new event?	Yes No
Is this service trip domestic or international?	Yes No
If off-campus, please answer the following questions:
Community partner organization name:
Community partner address (location where you will provide the service):
Community partner phone number:
Community partner email:
Estimated number of volunteers:
Means of Transportation:
Personal Responsibility – arranging my own transportation College provided through local bus company Name of Bus Company College provided using college owned/rented vehicle
Other comments or information:

Registration Form

*First name:

*Last name:

*Email address:

Status at St. Norbert College (choose one):

*Faculty

If faculty, please answer the following questions:

Course name

Course number

Is the service a required or optional component of the course?

Yes No

*Staff

If staff, please answer the following questions:

Department:

Name of service program:

*Student – Service as part of an academic course

If a student participating in service as part of an academic course, please answer the following questions:

Course name:

Course number:

Course instructor:

*Student – Service project for a student organization or student group

If a student participating in service for a student organization or group, please answer the following questions:

Organization name:

Advisor:

Advisor email:

Service Information

One time service event/program On-going service

Date you will be serving:

Provide a brief description of the service activity:

Share any risks you are aware of:

Is this a new event?

Yes No

Is this service trip domestic or international?

Yes No

If off-campus, please answer the following questions:

Community partner organization name:

Community partner address (location where you will provide the service):

Community partner phone number:

Community partner email:

Estimated number of volunteers:

Means of Transportation:

Personal Responsibility – arranging my own transportation
College provided through local bus company

Name of Bus Company

College provided using college owned/rented vehicle

Other comments or information:

Patricia Dart