Student Volunteer Application: Outreach

Date
*

First Name
*

Last Name
*

Address 1
*

Address 2

City
*

State
*

Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Date of Birth
*

Citizenship
*

Marital Status
*

Occupation
*

T-Shirt Size
*

Why do you want to go on this outreach?
*

Do you have any foreign language skills? What language(s)?
*

What other skills do you have that might be utilized on this outreach?
*

Have you ever been on an outreach/distribution before? Where? If so, what was your experience like?
*

Do you know of any reason that you may have difficuly functioning in a foreign country?
*

Have you ever been convicted of a felony?
*

This information is solely for the ROC Wheels, Inc. staff

MEDICAL INFORMATION

Do you have any dietary restrictions?
*

Yes

No

Please explain.

Is there any medical or physical reason why you would have to restrict yourself from strenuous activity?
*

Do you have any allergies to food, medicine, or the environment?
*

EMERGENCY CONTACT

Name
*

Phone
*

E-mail
*

Relationship
*

REFERENCE

Please give the name of someone (non-relative) you know for a personal reference.
*

Phone
*

Email

Address 1

Address 2

City
*

State
*

Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

BIOGRAPHY

Please write a short biography below. The biography will be used to share with other volunteer team members as an introduction prior to the beginning of the project.
*

Parent Contact Information

Full Name
*

Address (If different from yours)
*

Phone
*

Email
*

Signature

Please sign the application by typing your full name in the box below.
*