Email Address:

Address:     [apt. #]:

City:     State:     Zip Code:

Phone Number: ()-

SSN#:

Driver's Lic#:

Emergency contact:     Relationship:

Address:     Phone Number: ()-

Accommodations Needed:

Languages:

Spanish

French

Asian

Hand Signing

Other Languages:

Volunteer/Background:

Referral {How did you find us?}

Days available (Please check all that apply)

M

T

W

Th

F

A.M. [10-1]

P.M. [1-4]

Other (Please Specify)

Comments:

Computer: MSWord     MSAccess (Data entry)

Filing
Receptionist/Phone
Mailings
Preparing Newsletter
Library/Research
Transcribing (cassettes, braille)
Reading/Writing (correspondence, bills, etc. for visually impaired)
Systems Advocacy (phoning, letter writing, arrange for speakers, etc.)
Field Surveys on Accessible Housing (training and mileage reimbursement provided)
Public Relations
Peer Support (Must have a disability)
Fund Raising
Gardening
Photography
Accounting/Auditing
Carpentry/Handyman
Interpreting (sign, finger spelling, Spanish, etc.)