* 1. Last Name

* 2. First Name

* 3. E-mail

* 4. Cell phone

* 5. Emergency Contact Info (name and phone number)

* 6. Health Insurance Company AND Policy Number

* 7. Your Service Site

* 8. YOUR COMMITMENT TO EFFECTIVE CITIZENSHIP & SERVICE
I will not possess or use alcohol or other controlled substances while participating in any events sponsored by the Office of Active Citizenship and Service/Vanderbilt University. I understand that the use of alcohol or controlled substances may result in my dismissal from this program with any costs for return to Nashville,TN to be at my own expense. I also understand that my actions may jeopardize participation in other OACS-related programs. I recognize the need for this commitment to effectively participate in this program.

SIGNATURE:

T