Saturday, October 15th, 2005
9am - 3pm
PARTICIPANT INFORMATION
(For individuals registering with a group ONLY)
Please complete this form and bring it to the registration table at Cal Community
Action Day on Saturday, October 15, 2005 @ 9am.
GROUP NAME: _______________________________
PARTICIPANT INFORMATION
Name: ____________________________________
SID #: ____________________________________
Year @ Cal: _______________________________
Major: ____________________________________
Address: ___________________________________
___________________________________
Phone: ____________________________________
Email: ____________________________________
Do you have any special needs that we should know about as we choose your service
site? If so, please elaborate.
EMERGENCY CONTACT INFORMATION
Please fill out the following information so that Cal Corps and/or your Team Leader can
properly assist you should an emergency arise. Providing this information will expedite
our ability to help you if you are injured or in danger. This information will only be used
in case of an emergency.
Name of Emergency Contact Person: _______________________________
Relationship to Participant: _______________________________________
Address: _________________________________________________________
Phone #: _____________________ Alternate #: ____________________________
Current Medications: ____________________________________________________
Medical Conditions/Allergies: _____________________________________________