Pennies for Haiti Volunteer Form

About me
Full Name: *
Driver's License Number *
Gender *

Male Female
Birth Date: *

Month Day Year
I am over 18. If you are a high school student please seek approval from your school for your hours served. *

Yes No
Phone Number: *
E-mail Address: *
Home Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
My interests
My main areas of interest are: *
I can offer the following skills, knowledge and expertise: *
Which of these needs are you skilled in: *

Grant Writer Fundraiser Events Other
What would make you feel that your volunteering experience has been a success? *
My emergency contact

Please provide the details of someone we can contact in the unlikely event of accident or illness while volunteering for Pennies for Haiti.
Emergency Contact's Name *

First Name Last Name
Relationship *
Emergency Contact E-mail Address *
Phone Number *
Alt. Phone Number *
Full Name: *
Relationship to you: *
Contact number: *
Thank you

for your interest in volunteering with Pennies for Haiti.
Please enter the message as it's shown *
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