Are you wishing to register for this event as a participant or a site leader? *
- Select Option Participant Site Leader

First Name: *

Last Name: *

GVSU Email: *

Phone Number: *

Are you registering for the Make A Difference Day as a part of a group of students? (ex: Student Organization, Friend Group, Class) *
- Select Option Yes No

If you answered yes to the previous question, please list the name of the group you will be attending with. *

Are there any accommodations that need to be made for you to participate in Make A Difference Day? *
- Select Option Yes No

If you are in need of accommodations, please list below: *

Do you have any dietary restrictions? *
- Select Option Yes No

If you have dietary restrictions, please list below: *

Emergency Contact First and Last Name *

Relationship to you: *

Phone Number: *

Email: *

Behavioral Contract

I understand that as a member of the GVSU community, I will conduct myself in a professional, safe manner during the program and will strive to represent well Grand Valley State University. I understand that this program is a privilege that will be immediately revoked if I violate any of the following standards:

1. I will travel with my group at all times and will not venture out by myself. 
2. I will arrive on time to all designated travel departures, and I understand I may have to seek alternate transportation at my own expense if I am not present at departure time. 
3. I will abide by all Grand Valley State University policies, conduct rules, and laws of the land at the service location. I understand that any violation of the above standards will cause an immediate trip back to GVSU at my expense.

Do you agree to the Behavioral Contract? *
- Select Option Yes No

Photo Release: I give Grand Valley permission to use photos taken of me while volunteering for promotional purposes in Grand Valleys newsletter, mailings, and/or website. Do you agree with the previous statement? *
- Select Option Yes No

If you are participating in this event for a class, or are being paid to attend as a GVSU student employee, you are not required to agree to the following contract:

Travel Release Statement Assumption of Risk and Release for Off Campus Activities

RELEASE EXECUTED by the undersigned to Grand Valley State University, One Campus Drive, Allendale, MI 49401 IN CONSIDERATION of being permitted to participate in a voluntary activity that will involve travel off campus grounds offered through Grand Valley State University, I the undersigned, in full recognition and appreciation of the dangers and hazards inherent to participating in this activity/program to which I may be exposed during my enrollment and/or participation in this activity/program, do hereby agree to assume all the risks and responsibilities surrounding my participation in this activity/program or any independent activities undertaken as an adjunct thereto; and further, I do for myself, my heirs, and personal representative(s) hereby defend, hold harmless, indemnify, and release, and forever discharge and all its officers, agents and employees from and against and all claims, demands, and actions, or causes of action, on account of damage to personal property, or personal injury, or death which may result from my participation, and which result from causes beyond the control of, and without the fault or negligence of Grand Valley State University, its officers, agents, or employees, during the period of my participation as aforesaid.

Please select one of the following in regards to the Travel Release Statement Assumption of Risk and Release for Off Campus Activities: *
- Select Option I agree I am participating in this event for a class or being paid to attend as a GVSU student employee

COMPLETE IF UNDER 18 - An email will be sent to your parent or guardian via the email address you provide below. Your parent or guardian must use this email to approve your submission in order for your form to be approved. *

Community Partner Name *

Site Address *

Name of person who will communicate with the CSLC *

Email *

Phone *

What is the preferred number of students you are able to host at your site? *

Please provide a brief description of what the students will be working on. *

Is there any other relevant information that you would like to share with the CSLC? *