R3 Inc. Volunteer Application

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CONTACT INFORMATION

First Name *

Last Name *

Address *

City & State *

Zip Code *

Contact Number *

Email Address *

Best method and time to reach you? *

Emergency contact *

Please provide name, number and their relation to you.

Do you speak any other languages other than English? *

Please list them below. If none, please enter "NONE"

Please describe any skills or experience that would support your interest in volunteering with R3 Inc. *

Do you have any medical conditions that may affect your ability to function as an R3 Inc. volunteer, or do you require any special accommodations that the R3 Inc. coordinator of volunteers should be aware of? *

If "YES" please list below. If "NO" please enter "NO" or "NONE"

Are you licensed and able to drive an automobile? *

Note: If you will be driving to and from R3 Inc. events or to conduct R3 Inc. outreach activities, you will need to provide a copy of your driver's license and proof of insurance. We will collect this information at a later point in the screening process.

Certain conflicts between personal interests and the interests of the R3 Inc. program may exist, and could prevent a person from serving as an R3 Inc. volunteer. One example is that of a licensed health insurance agent. Some conflicts of interest, however, can be addressed in other ways and may not prevent someone from serving with the R3 Inc. program. If you have a business or other personal interest that may create a conflict, please describe it here so we can discuss it fully during your interview. *

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