Youth Volunteer Ambassadors Registration Form

Registration Form

Youth Volunteer Ambassadors
’Here’s a group of people who simply want to help other people whose lives are out of control.’

Inspiring Our Future 360° founded and led by Dr. Jermaine Gordon in 2016 is one of his newest initiatives to rescue youths by equipping them with habits necessary for success.

Our motto is: ’Treat a child the way you want your future to be.’

We want YOU to become one of 5,000 youths who is actively helping other youths to discover and activate the genius in them.
* Please note that all personal information on this application form is highly confidential. It will only be used for the purpose for which it was collected and won’t be disclosed to any other parties.
Personal Information

Please enter the information of the individual signing up.
Name*

First NameLast Name
Birth Date

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Mobile Number*
How old are you?*

12-1718-2526-3031-3536 and older
Parent / Guardian Information

For individuals under the age of 18, permission is required from a parent or guardian. This section must be filled out by the individual registering parent or guardian.
Enter Parent / Guardian's Contact information

Parent / Guardian's Name   First Name*   Last Name*

Parent / Guardian's Contact   Area Code*   Phone Number*

Parent / Guardian's Signature
Signature*
Work Experience and Volunteering History

Provide us with information about your work experience and volunteering history
Do you have any volunteer experience?*

Rows	Mornings	Evenings	Some Mornings	Some Afternoons
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Registration Form

Personal Information

Parent / Guardian Information

Work Experience and Volunteering History

Availability

Areas of Interest

Background Information