Professional Recruitment/Service Activity Form

Professional Recruitment/Service Activity Form

Each student is required to participate in at least one recruitment or service activity per academic year while enrolled in the Doctor of Occupational Therapy program at the University of Central Arkansas. While activities conducted in collaboration with student organizations (SOTA, SCDOT, PTE) are acceptable, activities that are part of a class are not. Please note that the department has materials for you to use during these recruitment/professional activities if needed. Advance notice is required to use department materials.

In order to receive credit for participation, each student must complete this form per activity. For team activities, one person will complete the form for the team.

Name of person completing this form * First Last
Your email address
What was your role at the event? *
If activity was conducted as a team, list all team members and their roles.
Select options that best describe you or team. * Class of 2022 Class of 2023 Class of 2024 Multiple Cohorts Program Advisor Faculty Staff
Project/Event Start Date * / MM / DD YYYY
Project/Event End Date * / MM / DD YYYY
Name of Event *
Type of Event *
What organization or facility was the event affiliated with? * ACTS ACTS in the Rock ACTS Jr Arkansas Down Syndrome Association Conway Public Schools Faulkner County Juvenile Drug Court PTE SCDOT SOTA SPOT Department of Occupational Therapy Other (please specify below)
If OTHER organization, please specify.
Age range of attendees * Birth to 5 years 6 to 12 years 13 to 17 years 18 to 21 years 22 to 65 years 65+ years
Describe the attendees
Number of people you came in contact with at the event: *
Select the best option to the following statement:
__________ of the attendees were representative of a minority or under represented group. *
Brief Summary of Event *
Any additional information:

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