2021-2022 Street Team Application

About You

First name

Last name

Date of birth (mm/dd/yyyy)

Street address

City

Zip code

Your Patient's Phone number (###-###-####)

Your Patient's Email Address *

Name of school or college:

Class year

Extracurriculars:

College Students: If your school is not in WNY, how would you like to stay involved?:

References (should not be a parent or other relative of applicant)

Reference

Phone: ###-###-####

Relationship i.e. teacher, coach, etc.

Reference

Phone: ###-###-####

Relationship i.e. teacher, coach, etc.

Please include a personal essay (250 words or more) explaining why you would like to be a Street Team member and what qualities you can bring to the team.

Are you interested in hosting a fundraiser to raise money for Roswell Park? *

Yes No

How did you hear about the Street Team?*

Please explain *

I understand that this position is voluntary and I agree to complete orientation.

Checking "I agree" constitutes as your legal signature.

I agree

Name of parent/guardian if 18 or under:

Guardian's first name

Guardian's last name