North Carolina Outreach Challenge Hours Submission Form
2019 Deadline is 9/25/19!!!

Please fill out all of the required fields below in order to submit your volunteer hours for the North Carolina Outreach Challenge.

A few things to keep in mind:
-This is a competition between North Carolina DPT and PTA programs, so please make sure that you write the correct school when submitting your hours.

-If your DPT or PTA program requires you to complete volunteer hours, you may NOT submit those hours for the NC Outreach Challenge. All hours submitted to this competition must be on a true volunteer basis.

-Volunteer hours do NOT have to be physical therapy related! Any volunteer work that you do may be submitted for this competition. Our goal is to highlight all of the positive contributions DPT and PTA students are making in their communities!

-Please fill out one form per volunteer activity. If this is an experience you complete regularly (ie once a month, every Saturday, etc), please indicate the total hours for the month and provide a description of how often you participate.

-NOTE: only hours from October 1, 2018-September 25, 2019 will count!


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First Name *
Last Name *
Your email address *
Are you a DPT or PTA student? *
What North Carolina DPT or PTA school do you attend? *
Date of Volunteer Activity *
MM
/
DD
/
YYYY
Total Volunteer Hours: *
Name of Volunteer Organization Contact: *
This is a person who works for the organization you volunteered with and could verify your hours. If you volunteered at a community-based clinic your school sponsors, please provide the name and contact information for one of your instructors.
Phone Number or Email Address for Volunteer Organization Contact: *
Please provide the phone number and/or email address for the volunteer organization contact person.
Please tell us briefly about your experience!
This volunteer experience was required as part of my program *
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