Providence College Urban Action Program Registration Form

Thank you for your interest in participating in the Urban Action program. Please fill out the application below. Urban Action applications will be due on Friday, July 12^th. You will be notified if you have been selected during the week of July 15^th. The program will take place from August 25-29, 2024.

All students who apply to Urban Action must submit their immunization and health record information to the Student Health Center NO LATER THAN JULY 12TH in order to be considered for the program. The Health Center patient portal will begin accepting immunization and health record information in mid-June. Visit the health center website for more information.

I understand that in order for my Urban Action application to be considered, I must submit my immunization and health record information by July 12th.

Note: The health forms must only be submitted to the Health Center by 7/12, they do not need to be reviewed and marked compliant by the Health Center by 7/12. The Health Center will review records over the summer and reach out separately if they have any questions.

Name (First and Last):

Birthdate:

Cell Phone #:

Home Phone #:

Home Street Address:

City:

State:

Zip Code:

PC Email Address: (@friars.providence.edu)

Please list any dietary restrictions:

Please describe any previous service experience you have had. What did you learn? If you haven’t done service, what do you expect of service in the UA program?

What do you hope to gain from participating in the Urban Action program?

What concerns do you have, if any, about participating in the Urban Action program?

Contact Information