ServeWyoming service learning project applicationName * Required First Last Phone * RequiredEmail * Required Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Student ID # * RequiredDate of Birth - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Program of Study * RequiredAccounting (AAS, AB, C)Addiction Studies ( AS, PC)Agri-business (AAS, AS)Agriculture (AS)Agriculture Communication (AS)Animal Science Technology (AAS, AS)Anthropology (AA)Architectural Graphics & Design (C)Art (AA)Art Education (AFA)Assistive Technology (C)Athletic Training (AS)Auto Body Repair (AAS, C)Automation (C)Automotive Technology (AAS, C)Aviation (AAS)Biology (AS)Business Administration (AB)Chemistry (AS)Cognitive Retraining (PC)Communication (AA)Computer Science (AS)Computer Security (AS, AAS, C)Computed Tomography-CT (PC)Construction Management (AS)Construction Technology (AAS, C)Criminal Justice (AA, AAS)Dance Performance (AA)Diesel Power Technology (AAS, C)Dispatch (C)Early Childhood Education (AA)Economics (AS)Electrical Apprentice (C)Electronics Technology (AAS)Elementary Education (AA)Engineering (AS)Engineering Technology & Design (AAS)English (AA)Entrepreneurship (AAS)Environmental Science (AS)Equine Assisted Therapy (C)Fine Art (AFA)Fire Science Technology (AAS, C)Forensic Science (AS)General Studies (AA, AS)Geographic Info. Systems (AS, C)Geology (AS)Gerontology (C)Graphic Design (AFA)Health Science (AS)History (AA)Hospitality Management (AAS)International Studies (AA)Leadership and Organizational Management (AAS)Liberal Arts (AA)Machine Tool Technology (AAS, C)Magnetic Resonance Imaging-MRI (PC)Mammography (PC)Management (AAS)Manufacturing Technology (AAS, C)Marketing (AS, C)Mathematics (AS)Mechanical Graphics & Design (C)Medical Lab Technician (AS)Museum/Gallery Studies (AA)Music (AA)Music Education (AFA)Music Performance (AFA)Musical Theatre Performance (AA)Nursing (AAS, AS, ADN)Nutrition (AS)Occupational Therapy Assistant (AS)Office Management (AAS, C)Paralegal Studies (AA, Post Bac. Cert.)Paramedic Technology (AS)Pharmacy Technology (AS, C)Phlebotomy (C)Photography (AFA)Physical Education (AS)Physics (AS)Political Science (AA)Pre-Dentistry (AS)Pre-Law (AB)Pre-Medicine (AS)Pre-Occupational Therapy (AS)Pre-Optometry (AS)Pre-Pharmacy (AS)Pre-Physical Therapy (AS)Pre-Veterinary (AS)Process Technology (C)Psychology ( AS)Radiography (AS)Range Management (AS)Renewable Energy Technology (AAS, C)Respiratory Therapy (AS)Retail Management (C)Retail Merchandising (AAS)Robotics Technology (AAS, C)Secondary Education - Mathematics (AS)Secondary Education – Social Studies (AA)Social Work (AA)Sociology (AA)Software Application (C)Statistics (Applied) (AS, C)Technical Education (AS)Technical Studies (AAS)Theatre Performance (AA)Theatre Technology (AA)Web Design (AAS, C)Web Development (AAS)Welding (AAS, C)Wildlife and Fisheries Biology and Management (AS)Women’s and Gender Studies (AA, C)World Languages (AA)Faculty/Advisory Contact * RequiredService Learning Class (if applicable)What areas of interest and/or expertise could you bring to Service Learning?Please select all that apply. We will make every effort to find the best fit for your interest and skills. Finance and accounting Human resources Fund development Information Technology IT - Technology assessments IT - Database use and design IT - Networking/email IT - Web development and maintenance IT - PC hardware setup and configuration IT - General application usage Graphic design Marketing, public relations Program design and evaluation Nonprofit management Board development Strategic planning Legal affairs OtherIf "Other" is selected above, please explain:Briefly describe your background, experience, and/or interests in the area(s) you checked above. * RequiredHave you ever volunteered with a for-profit or non-profit organization? If so, what agency did you help and what were your responsibilities?Agreement to follow rules and procedures: * RequiredBy submitting this contract, I agree to follow all rules and procedures including completing the ServeWyoming Volunteer Management Training, tracking and having hours signed by appropriate nonprofit/agency staff.YesConsent: * RequiredI hereby consent to permit Casper College to conduct a search of state criminal history information and a fingerprint-based FBI check for selection and compliance purposes. I understand that selection into the program is contingent upon successful clearance of these checks and a search of the National Sex Offender Public Website (NSOPW). I understand that if I have been convicted of murder or if I am required to be registered as a sex offender I am ineligible to work or serve in this position.YesYou will be asked to sign-off on the required background checks and eligibility verification tasks when meeting with Rachel Chadderdon, the service learning coordinator at CC.