Volunteer Registration

If you want to register on-line, please fill out the form below. The marked are required fields. Pressing the enter key is the same as clicking once on the Submit button with the mouse.

Mr.

or Ms.

Date of birth (mm,dd,yyyy)

/


First Name

Last Name

Phone

Fax

Street

St.

City

ZIP

E-mail


What is your Ethnic Origin?

Asian/Pacific Island Black Hispanic Native American
White

Do you have disability?

Visual Hearing Wheelchair Walker/Cane

Do you drive?

Do you drive?
(mark if yes)		 Liability insurance?
(mark if yes)		 Driver´s lic.#

Emergency contact peron to handle insurance matters if injured

First Name

Last Name

Phone

Street

St.

City


Please check any of the following skills or interests you have

Arts and Crafts
(if so, what do you do?)

Environment

Media

Audio Visual

Financial
(Bookkeeping, Clerking)

Human Needs Issues

Board Member

Friendly visitor
(Nursing Homes, Homes)

Nutrition
(Meals/Wheels, Senior Meals)

Clerical

Games or Hobbies
(if so, what?)

Advocacy

Computers
(if so, what kind?)

Home-Based

Public Safety
Warmline, Police, Community

Construction or Maintenance

Cooking or Baking

Senior Centers

Desktop Publishing

Medical or Health

Cultural Heritage
Folk Fairs, Historical Society

Education and Literacy

Entertainment
Sing, Dance, Instrument, Stories