1 Volunteer2 Parents3 Signature Submission IDDebugAge*Under 18 years old18 years or olderVolunteer's Name* First Last Birth Date*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleAddress* 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 PhoneCell Number*Cell Carrier*Email* Highest Level of Education*High SchoolSome College2 Year College Degree (Associates)4 Year College Degree (BA/BS)Master's DegreeDoctoral DegreeSchool*Grade*7th Grade8th Grade9th Grade10th Grade11th Grade12th GradePhoto*Accepted file types: jpg, gif, png, pdf, jpeg.Temple AffiliationMedical InfoAny allergies?*YesNoPlease specify*Please list any medical conditions that we should be aware ofEmergency Contact Name* First Last Emergency Cell*VolunteerVolunteer in the Shoppes Which days are you available to volunteer during the mornings from 9:30-12:30pm? 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 Which days are you available? 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*MotherFatherGuardianResponsible Party's InfoMother's InfoFather's InfoGuardian's InfoName* First Last OccupationCell Number*Cell Carrier*E-mail* Parent’s Status*MarriedWidowedDivorcedSeparatedOther Parent's InfoMother's InfoFather's InfoOther Guardian InfoName* First Last Occupation*Cell Number*Email* Parent ConsentParent ConsentMy child needs assistance while volunteering.My child can volunteer independently.Does your teen babysit independently for children other than family?*YesNoVolunteer ConsentCOVID 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.*YesNoVolunteer Status*I am a new volunteer at LifeTown.I have volunteered before at LifeTown.Signature*CommentsPhoneThis field is for validation purposes and should be left unchanged.