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Volunteer Registration

First Name:

Last Name:

DOB:

Email:

Phone:

Address:

Are you a person with a disability?:

If Yes:

-- Disability Type:
-- Description:
-- Date of injury/diagnosis:
-- Cause of injury:

If No:

-- Does your family member (or loved one) have a disability?:
-- Tell us more:

Gender:

Do you speak any additional languages?:

-- Languages:

Emergency contact name:

Emergency contact number:

Are you volunteering for a class or project?:

If Yes:

-- School:
-- Area of study:
-- Professor's name:
-- Number of hours needed:

Do you have any restrictions on lifting (25-50 lbs)?:

Do you feel comfortable lifting (50+ lbs) ex: Transferring?:

Do you have any special accommodation requests?:

Accommodation Request:

Do you have any criminal history?:

If Yes:

-- Provide a full explanation of the conviction or pending charges. (A conviction or pending charge will not necessarily disqualify you from volunteering. Each situation will be considered on its own merits.):

How did you hear about us?:

Are you under the age of 18?:

If APPLICANT IS UNDER THE AGE OF 18, A PARENT OR GUARDIAN SIGNATURE IS REQUIRED.

PARENT OR GUARDIAN PLEASE SIGN THIS FORM.

Parent/Guardian Name:

Relationship:

I agree to be on-site and provide supervision during the volunteer service:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signed by Andrew Skinner
Signed On: January 21, 2022

Timestamp

Audit

May 18, 2020 2:14 pm PDT

Volunteer Registration Uploaded by Andrew Skinner - [email protected] IP 2600:8800:8028:4d00:35cf:5602:17a:a1fe