Contest Application

Team Name:
Team Captain Information
First Name:		Last Name:		E-Mail:
Date of Birth:	(mm-dd-yyyy)
Home Phone:		Cell Phone:
Address:				City:
Province:		Postal Code:
Other Members' Information
First Name   Last Name   Date of Birth (mm-dd-yyyy) 1)     2)     3)     4)     5)     6)     7)     8)     9)
Charitable Activity Information
Where will your team's activity take place? (e.g. address, city, intersection, park):
When will your team's activity take place? (date and time):
Who or what will your team make a positive difference for?:			Approximately how many people will benefit from your team's activity?:
seniors orphans single mothers widows women and children living with violence or abuse youth at risk or in gangs people living in poverty the environment immigrants/newcomers or refugees people who are homeless people living with mental health problems people living with addiction people living with physical or developmental disability people living with illness or disease animals other			Under 10 11 - 20 21 - 30 31 - 40 41 - 50 Over 50
Will your team be representing a school, business, charity, social club or any other type of organization?:			Will your team be entering into a partnership with any organization or business for the purpose of your charitable activity?:
Yes No			Yes No
How will your team make a positive difference? (max. 500 words) (eg. nature and scope, expected outcome or impact of your team's activity):
I have read, understood, and agreed to or accepted, the rules, as well as any and all terms and conditions of the Good Samaritans Contest, and Awliya Community Services' privacy policy.

* Indicates mandatory field.