16TH ANNUAL
GREATER PHILADELPHIA
MARTIN LUTHER KING DAY OF SERVICE
Pennsylvania . New Jersey . Delaware
Monday, January 17, 2011
GIRARD COLLEGE SIGNATURE SITE
REGISTRATION FORM
WHEN COMPLETING THIS FORM PLEASE NOTE:
Type or print clearly-- you may attach a business card where appropriate.
Please complete one form for each project and number each project (i.e. 1,2,3).
ONLY fill out the application section that applies to your project(s) (i.e. if your project is with the Kids Carnival, only fill that section).
Keep Dr. King’s principles of equal opportunity, social change, and economic justice in mind when developing your project(s).
Questions? Contact Diana Misdary at (215) 665-2506 or dmisdary@globalcitizen.us.com.
Registration deadline for all participants is December 3rd, 2010.
I. Project Coordinator Information (Required for all projects)
The project coordinator is the leader of your project and the liaison with our headquarters. The project coordinator is responsible for all
aspects of the project such as providing materials, setting up, etc.
A. Project Coordinator (Name and Title):
B. Organization:
C. Mailing Address:
(City) (State) (Zip Code)
D. Phone: Day ( ) Evening ( ) Fax ( )
E-mail: Alternate E-mail*:
Website: *Please provide an e-mail address where you can be reached during non-business hours.
E. Please check the issue(s) that your organization works to address. Select all that apply.
□ Technology/Digital Inclusion □ Intercultural Connections □ Environment/Energy
□ Public Safety □ Healthcare □ Education
□ Homelessness □ Other Area:
II. Volunteer Service Project or Workshop
SKIP this section if you are ONLY participating in the Kids Carnival, Civic Engagement Expo, and/or the Health & Wellness Fair.
A. Project title: _________________________________________________________________________
B. Project description (will be printed in event program; attach separate sheet if necessary)
C. Is this project kid friendly? (Please check one) _____YES _____NO
D. Is this project wheelchair accessible? (Please check one) _____YES _____ NO
E. What age range(s) of volunteers will be involved in this project? Ages □ 5-9 □ 10-13 □ 14-18 □ 19-64 □ 65+
F. How many total volunteers do you need to complete this project? _________________________________________
G. How many volunteers will you provide? ____________________________________________________________
H. Can the King Day of Service headquarters provide volunteers? (Please check one) _____YES _____ NO
If YES, please complete the “Volunteer Recruitment” section in FULL. If NO, skip that section.
I. In addition to registered volunteers, can your project accommodate “walk-in” volunteers? _____YES _____NO
III. Volunteer Recruitment Information
Please complete ONLY if you would like our headquarters to provide you with volunteers to assist you with your projects.
A. How many additional volunteers would you like from King Day of Service headquarters? # of Volunteers:
B. What age range(s) of additional volunteers would you like for this project?
(Check ALL that apply) □ 5-9 □ 10-13 □ 14-18 □ 19-64 □ 65+
C. What specific tasks will the volunteers be required to perform? (not the same as description)
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IV. Kids Carnival Project Information
ONLY fill out this section if you plan on participating in a project at the Kids Carnival.
A. Type of project(s): _____ Performance _____Arts and Crafts _____ Demonstration _____ Other
If other, please explain: ________________________________________________________________________________
B. Please offer a brief project description and a project title. This will be printed in the event program (attach sheet if
necessary):
C. This project is appropriate for children ages (check all that apply):
____ 5 & under ____ 5-9 ____ 10-13 ____ 14-18
V. Volunteer Expo Information
ONLY fill out this section if you plan on participating at the Volunteer Expo.
A. Please give a brief description of your organization. This will be printed in the event program (attach sheet if necessary):
B. Please give a brief description of volunteer opportunities at your organization. This will be printed in the event program
(attach sheet if necessary):
VI. Health and Wellness Fair Information
ONLY fill out this section if you plan on participating at the Health and Wellness Fair.
A. Health topics to be addressed:
B. Type of exhibit (check all that apply): _____ Information Distribution _____ Testings/Screenings
_____ Demonstration _____ Other
C. Please provide a brief description of the exhibit and a project/exhibit title. This will be printed in the event program (attach
sheet if necessary):
VII. Set-up Requirements (Required for all projects)
A. Equipment and Space needs: What are your needs for this project?
# of Tables:______ # of Chairs: _____ # of Electrical outlets/hook-ups: _____
Materials you will provide for your project:
B. Do you have any specific space needs? Please provide further information that may help us assist you at the Signature
Site:
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Please note that project set-up at Girard College will take place the weekend of January 15-16 and the morning of the 17 before
7:30am. Please contact our headquarters to coordinate any special moving and/or set-up arrangements.
P l e a s e r e t u r n t h i s e n t i r e f o r m v i a f a x o r m a i l b y December 3, 2010
GREATER PHILADELPHIA MARTIN LUTHER KING DAY OF SERVICE
c/o Global Citizen 1709 Benjamin Franklin Parkway Philadelphia, PA 19103
Phone 215.665.2475 Fax 215.665.2647 Email dmisdary@globalcitizen.us.com
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