Name
Local Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
E-mail

Please provide to us your Summer Address (if applicable):

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

Choose one of the following options:

I live here all year
I am a winter resident

If you are a winter resident, please tell us what dates you visit us.

During which days are you available for volunteer assignments?

Monday
Tuesday
Wednesday
Thursday
Friday

What time of day are you willing to volunteer?

Mornings Afternoons Either Both

Tell us in which areas are you interested in volunteering. (Please choose all that apply)

Administration
Patient Advocate
Events
Field Work
Fundraising
Courier
Volunteer coordination

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.

Summarize your previous volunteer experience.

Person to notify in case of emergency.

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Cell Phone
Work Phone
Home Phone

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Name

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