U.T. House Medics - Fall Campaign 2008

Click here for information about House Medics

INSTRUCTIONS:

Fill in the blanks with the appropriate information. At the end of this form, you will send this information via e-mail to the appropriate area for processing.

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Last Name:
First Name:
School/Operating Unit:
Department:
Inter-Institutional Address:
Phone:
E-mail:

T-Shirt Size: Pending funding source.

S

M

L

XL

XXL (Only Adult Sizes Available)

I am:

Yes	No
		Faculty/Alumni
		Staff/Administration
		Student
		Resident/Fellow
		Family/Friend **
		Other **

** - Include name of Employee for team assignment:

Which Days are you available?
(Both days are not required - Half days are welcome too - Please specify in comments if half day)

Yes	No
		Saturday, October 19th, 2007
		Saturday, October 25th, 2007

Participation

Yes	No
		I have participated in U.T. House Medics before
		My Skills Include:
		No Experience at all
		Painting/Hammering/Yard Work
		Repairs/Use saw
		Skilled carpenter/electrician

Special Projects

Yes	No
		I have been a Team Leader
		I will be a Team Leader
		I have a pick-up/van which can be used to carry supplies or lawn debris.

If you want to be on the same team as someone you know, include that here.
If you are a minore, please include your age and be sure to sign a Minor Release Form.
Also, please send us any additional comments or questions you may have here:

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Press one of the following buttons to either clear the values in the form or submit the request.