Worksite Project Request Form

Worksite Project Request Form

Your Contact Information
Your Organization's Name *
One Sentence Description of What Your Organization Does *
Your Name *

First Name Last Name
Your Title *
Your Email Address *
example@example.com
Your Phone Number: Office *
Your Phone Number: Mobile *
Will you be the onsite supervisor the day students come to volunteer? *

Yes, I will. No, someone else will be the day-of supervisor.

Onsite Supervisor
Provide the name and mobile phone number of the worksite supervisor, if someone other than you.
Who will be the Onsite Supervisor (person welcoming and supervising volunteers? *

First Name Last Name
Onsite Supervisor's Title *
Onsite Supervisor's Email *
example@example.com
Onsite Supervisor's Phone: Office *
Onsite Supervisor's Phone: Mobile *

Worksite Dates and Project Details

Service Project Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Special Instructions: Location and Connecting that Day *
Please select ALL dates that you would like to host a group of volunteers. *

Monday, June 24, 12:30 - 4 PM Tuesday, June 25, 12:30 - 4 PM Wednesday, June 26, 12:30 - 4 PM Monday, July 15, 12:30 - 4 PM Tuesday, July 16, 12:30 - 4 PM Wednesday, July 17, 12:30 - 4 PM
THP Worksite Teams consist of students ages 12-18 and their adult leaders. What is the ideal number of people for you to host EACH DAY? We will do our best to meet these numbers. *

10 or less people 11-16 people 17-30 people
Service Project 1: What is the first and most important service project you would like students to complete? *
Service Project 2: If your worksite team(s) complete the first service project, what is the second most important service project you would like students to complete? *
Service Project 3: If your worksite team(s) complete the first two service projects, what is the third most important service project you would like students to complete?
Dream Big! What is something you would love to see but haven't had the staffing or volunteers to accomplish? If our worksite teams finish all the previous projects and have a chance to go above and beyond to bless your organization, what would that look like?
What supplies are needed for these service projects, and where are these supplies located at your organization? *
Your organization is responsible for providing all supplies and covering all costs for the service projects, unless a specific request is made to and approved by our Program Director. If you are requesting THP to provide any supplies or cover any costs, please list these below, and indicate the service project(s) for which they are necessary to complete.
Please include any comments or questions below.

Signatures
By signing electronically below, I agree to host a worksite team from The Hartford Project on the above selected date(s), and confirm that I or the otherwise listed onsite supervisor will be present to welcome and instruct volunteers upon arrival.

I also agree to keep students in safe working conditions and to never ask students to work with or near poison ivy.
Your Signature

Clear
Onsite Supervisor's Signature

Clear
Should be Empty: