Community Impact at Columbia University

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Please fill out and submit this form once you have begun working with a Community Impact (CI) program. If you are interested in volunteering for CI and want more information, please visit the CI office (105 Earl Hall) and consult the Student Coordinator list for the names of individual group coordinators as well as group contact information.


First Name:
Last Name:
Email: (Include @xxxx.edu)
School:
Graduation Year:
Permanent Residence:
Permanent Phone: (10 digits, no dashes)
Work-study:		Eligible Not Eligible Do not wish to specify

	The following two questions are used to compile demographic profiles of volunteers, which are often required by grant proposals:

	How would you classify your racial/ethnic identity?
	Asian/Asian American Black/African American Native American Do not wish to specify	Spanish/Hispanic/Latino White Other or Multiple
	Gender?
	Female Male Do not wish to specify

	What group will you be working with?
	Please indicate if you will be a:

Together we can make a difference.