Volunteer Interest Form Date Date Format: MM slash DD slash YYYY Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email Phone*Past Volunteer ExperienceOccupation (or past occupation if retired)Other information that will help us make a good match (such as education, general interests/hobbies)Languages SpokenAvailability and Volunteer Assignment Preferences*Mornings (Mon-Fri)Afternoons (Mon-Fri)Once A WeekMore Than Once A WeekOtherPlease Check All That Are Applicable *A commitment of 1x/week for 6 months is preferred, but adjustments can be made regarding the number of days per week/month on an individual basis. I prefer to work in theKitchen UnitMaintenance UnitBusiness UnitDo You Have A Valid (GA) Driver’s License?*YesNoLicense NumberDate of BirthHave You Ever Been Convicted For Violation Of Any Laws, Traffic Or Otherwise?*YesNoIf Yes, Please Explain.Who To Notify In Case Of An Emergency?*Telephone Number of Emergency Contact*Reference #1 Name* First Last Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.Reference #1 Email* Enter Email Confirm Email Reference #1 Phone*Reference #2 Name* First Last Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.Reference #2 Email* Enter Email Confirm Email Reference #2 Phone*Reference #3 Name* First Last Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.Reference #3 Email* Enter Email Confirm Email Reference #3 Phone*Upload Medical Clearance* Drop files here or Accepted file types: jpg, pdf, word. A document from a medical professional indicating the following: •The volunteer has been seen within the previous 12 months of the start date of volunteer activity. • Proof of a negative TB test, within the past 12 months. • A statement that the individual is Free of Sign and Symptoms of infectious diseases which may be transmitted to other participants and staff.Consent* I hereby give my consent to contact my references; to contact my employers, past and present; and to conduct a background check.This checkbox serves as a signature on this virtual volunteer form.EmailThis field is for validation purposes and should be left unchanged.