American Red Cross of the Tri-States
Community Services Event Form

Event/Project Name:
Start Date:	Start Time:
End Date:	End Time:
Organization/Business:
Address:
City:	State:	Zip:
Contact Person:
Phone Number:	E-mail Address:
Number of Workers/Volunteers
Youth (17 & under): ____	Young Adult (18-24): ____	Adult (25 & over): ____

Please Select One Activity that Best Describes Your Event/Project
____	Service Project (collection/production of items)	Number of Items:	____
____	Distribution of Disaster Preparedness Information	Number of People Reached:	____
____	Club Red Meeting	Number of Attendees:	____
____	Distribution of General Red Cross Information	Number of People Reached:	____
____	Presentation/Demonstration (Red Cross Information)	Number of People Reached:	____
____	Red Cross HERO'S Meeting	Number of Attendees:	____
____	Red Cross Fund Raiser	Amount Earned:	____
____	Other:

Comments/Details:
Form Completed By: ____________________________		Date: ________________

Send form to:
American Red Cross of the Tri-States
2400 Asbury Road
Dubuque, Iowa 52001