Membership Application Form for The Hope Shot

The Hope Shot is a recovery community organization that is committed to help people on their path to recovery. Bridging the gap and connecting those with substance use disorder to resources they need to thrive in society.

We encourage the participation of members who support our
mission and are willing to contribute. This can be contributed by volunteering, networking or by becoming a monthly donor.

The information provided through this form will be kept confidential and will help us determine which member you want to become. We welcome everyone that wants to join the mission and support the great work we are doing.

Name*

First NameLast Name

Birth date *

Date

Gender*

MaleFemale

Email*

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Are you in recovery?*

YesNo

Recovery Date*

Date

Short recovery story?*

High School Education?*

College education?*

YesNo

Degree?*

Company

Position

Which member are you wanting to become?*

Monthly DonorVolunteerBoth

In which areas would you like to volunteer?*

Other areas of volunteering?

Which of the volunteer activities interest you?*

Other volunteer activities?

Do you have any volunteering experience? If yes, please describe.

Select your available days*

From*

Hour Minutes

AM/PM Option

To*

Hour Minutes

AM/PM Option

Additional notes about your schedule

Signature*

Jotform

Yes

The Hope Shot

Lived Experience

Educational Background

Occupation