Volunteer Form

Volunteer Form
Hey, tell me about you...
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

CisgenderTransgenderOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Phone Number*

Area CodePhone Number
Volunteer Shirt Size*
How did you hear about us?
linkedin, facebook, instagram, etc.
Would you like to receive Melanin Motivated email updates?*

Sign me up!No, thank you!
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Drug Allergies or Other Allergic Reactions:
Health or Behavioral Conditions:
Dietary Needs/Restrictions:
Activity Restrictions:
Areas of Service:
What dates are you planning to attend?*

JulyAugustSeptemberOctoberNovemberDecember
In which areas would you like to volunteer?
Why do you want to volunteer with Melanin Motivated?*
Which of the volunteering activities interests you?
Please list any other info that would be helpful for us to know (ex. other skills, how much skill you have in certain areas, work limitations, etc):
If interested in skill-based volunteering, what skills can you contribute?

Thank you
for your interest in volunteering with the Melanin Motivated. If you have any current convictions, we may ask you to declare them when you come in for a chat with us. If you’re interested in a role that involves volunteering with children and / or vulnerable adults, we will ask for information about current and spent criminal convictions. Having a criminal record will not necessarily exclude you from volunteering with us.

Privacy Statement: The personal information above is collected in order to evaluate the volunteer candidates during the evaluation process. The information may be shared with program and organization partners.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Payment: The cost is $20 per volunteer shirt.
Payment
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Total Fee$20.00

Quantity

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Payment: The cost is $20 per volunteer shirt.