NAME:______________________________ EMAIL ADDRESS:____________________

ADDRESS:___________________________________________________________________

PHONE NUMBER:____________________ FAX NUMBER:_______________________

EDUCATION:________________________________________________________________

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PAST VOLUNTEER EXPERIENCE:_____________________________________________

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What skills do you have to offer?_________________________________________________

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Indicate the level of commitment that you are comfortable with. Please circle yes or no in response to each statement.

YES NO Maybe I will participate with fund-raising when needed.

YES NO Maybe I am interested in participating in public forums.

YES NO Maybe I want to become involved with group work matched with my interests and abilities.

YES NO Maybe I want to attend meetings and receive mailings.

What is your motivation for volunteering at present?________________________________

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Availability:__________________________________________________________________

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What would you prefer not to do?__________________________________________

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