Volunteer Intake Form We believe in the ability to transform communities through the power of volunteers. Volunteering can be a deeply rewarding experience where you can make immediate and lasting change by improving lives and building a stronger community. Personal InformationName* First Last Date of BirthoptionalMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Mobile PhoneHome PhoneWork PhoneWhat is the best way to contact you? E-mail Mobile Phone Home Phone Work Phone Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency Contact InformationEmergency Contact Name First Last RelationshipPhoneAdditional Information / AvailabilityWhat days are you available to volunteer? Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of the day are you available? Morning Afternoon Evening Are you a student volunteering to fulfill a certain amount of community service hours?YesNoName of School*Number of hours needed*Deadline date to complete required hours* Interests / QualificationsWhich areas you are interested in volunteering?Check all that apply. Advocacy Clerical/Data Entry Community Services Moving / Item Transport Events Mailings Off-Site Opportunities Skills / QualificationsPhysical / Medical LimitationsTERMS AND CONDITIONSVolunteer Agreement In agreeing to this liability waiver, I certify that I am a willing participant in the United Way of Essex & West Hudson (UWEWH) volunteer program. I agree to work according to instructions I receive. I agree to behave in a responsible manner. I agree to perform only work that I feel comfortable in doing and that I feel I can accomplish safely. Permission – Use of Photographs I grant permission to use individual and group volunteer photographs, films and videos of me for promotional or other uses furthering the mission of the UWEWH, including use on the UWEWH website. Acknowledgement and Assumption of Risk I recognize that the opportunity to participate in the UWEWH volunteer program may involve physical labor and may carry a risk of personal injury and I hereby agree to assume all risks which may be associated with my participation. I hereby release, discharge, waive and relinquish all claims, liabilities and damages I may sustain from bodily injury, personal injury or property damage and hold harmless the UWEWH, its officers, directors, employees and agents. CONSENT* By checking this box, I acknowledge that I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. 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