1Volunteer2Parents3Signature HiddenSubmission ID HiddenDebug Age* Under 18 years old 18 years or older Volunteer's Name* First Last Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneCell Number*Cell Carrier* Email* Highest Level of Education* High School Some College 2 Year College Degree (Associates) 4 Year College Degree (BA/BS) Master's Degree Doctoral Degree School* Grade*7th Grade8th Grade9th Grade10th Grade11th Grade12th GradePhoto*Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.Temple Affiliation Medical InfoAny allergies?* Yes No Please specify*Please list any medical conditions that we should be aware ofEmergency Contact Name* First Last Emergency Cell*VolunteerVolunteer in the Shoppes Monday Tuesday Wednesday Thursday We are looking for Adult volunteers who would be interested in being a 1:1 buddy for our young adults (21+) programming. All programming starts November, 20191:1 Volunteer Buddy Program Sundays | 12:15-2:30pm Mondays | 6-7pm Wednesdays | 5:30-7pm Saturday, November 16th | 7-9pm Allie’s Camp Sunday, December 22nd | 10-1pm Monday, December 23rd | 10-3pm Parent/Guardian InfoResponsible Party* Mother Father Guardian Responsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last Occupation Cell Number*Cell Carrier* E-mail* Parent’s Status* Married Widowed Divorced Separated Other Parent's InfoMother's InfoFather's InfoOther Guardian InfoName* First Last Occupation* Cell Number*Email* Parent ConsentParent Consent My child needs assistance while volunteering. My child can volunteer independently. Does your teen babysit independently for children other than family?* Yes No Volunteer ConsentHiddenCOVID procedures* I will stay home if myself or anyone in my household is not feeling well and if anyone has been exposed to or has COVID-19. I will inform Friendship Circle if I tests positive for COVID-19. According to the CDC guidelines, individuals who are fully vaccinated do not need to wear masks. Individuals who are not vaccinated including children 2 years and older should wear a mask covering their mouth and nose when in public. I have reviewed and agree to the following procedures: (Please check each item to confirm you have reviewed it. You must check all boxes)Code of Conduct Volunteer's Signature Actions Edit Delete There are no Code of Conducts. Add Code of Conduct Maximum number of code of conducts reached. Code of Conduct Volunteer's Signature Actions Edit Delete There are no Code of Conducts. Add Code of Conduct Maximum number of code of conducts reached. I allow my photos to be used for any and all LifeTown publicity purposes.* Yes No Volunteer Status* I am a new volunteer at LifeTown. I have volunteered before at LifeTown. Orientation Status* Yes, I came to an orientation. No, I have not yet attended an orientation. * I hereby give permission to the Friendship Circle-LifeTown administration to take whatever medical measures they deem necessary for my child in the event of a medical emergency. Signature*CommentsPhoneThis field is for validation purposes and should be left unchanged.