Name
*
Phone
*
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street or PO Box
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Sex:
*
Valid Driver's License
*
Yes
No
License Number
*
Are you willing to consent to a SLED/FBI background check?
*
Yes
No
I attest, under penalty of perjury that I am (check one of the following)
*
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
An alien authorized to work (Alien # or Admission #)
Alien #
*
Alien # or Admission #
*
until (expiration Date, if applicable - month/date/year)
*
School Preferences (Please Check)
*
Cottageville Head Start
Walterboro Main Office
Weatherization Office
Estill Head Start
Hampton Office
Safe Haven Shelter
If you can only volunteer certain days of the week please indicate the dates and times you are available:
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