Volunteer Registration Form
Host name: Eileen Shaffer
Camp dates: June 25 - June 29, 2018

Camp location/address: Tuscarora High School 801 North King Street Leesburg, Virginia 20176
We are pleased to offer this bike program to people with disabilities and look forward to having you play an important part in helping our special riders learn to ride a two-wheel bicycle independently

***NO PRIOR EXPERIENCE WORKING WITH PEOPLE WITH DISABILITIES IS NECESSARY***

AGE REQUIREMENT: Volunteers must be at least 15 years old

Volunteer Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
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YYYY
T-shirt size
E-mail address *
Your answer
Cell Phone *
Please enter 10 digits
Your answer
Home Address (Number and Street) *
123 Any Pl.
Your answer
Home Address (City) *
Wonderful
Your answer
Home Address State/Province *
Virginia
Home Address (Zip Code) *
24578 (5-digits)
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Please enter 10 digits
Your answer
Comments
Your answer
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