Student Community Service Hours Recycling Kit

Attention Guidance Counselors:

This form is for student enrollment in our program. If you are interested in publicity information for your school,

Privacy Policy: Your contact information, including e-mail address, will not be sold or disseminated to other people, organizations, or companies. Your information will only be used for communication between you and GRC Wireless Recycling.

First Name *

First Name

Last Name *

Last Name

Address *

Address

Address Line 2

Address 2

City *

City

State *

State

Postal Code *

Zip Code

Phone *

Phone

Email *

Were you referred to us by a specific shelter? If so, please choose Option B and enter the organization's name, city and state.

Your "partner" shelter (who benefits from your collection). Please choose one:

Partner Shelter *

Option A: Shelter Alliance will partner you with a shelter.

Option B: You want to partner with a specific shelter.

Note: With Option B, the shelter must be a current Shelter Alliance participant.

Organization Name

Organization City

Organization State

School Name *

Your School Name

Reason For Community Service *

Reason For Community Service

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