Disaster Relief Services Volunteer Registration Form
Hurricane Harvey 2017
Contact Information
First and Last Name *
Your answer
Gender *
Address *
Street
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email *
Your answer
Phone *
Your answer
Group Registration - Name of Group
Your answer
Availability *
Will Call You As/When Needed
Required
Are you 18 years or older?
If NO please provide Parent/Guardian consent. (Unfortunately we cannot accept anyone under 16)
Parent/Guardian Consent if 16 or 17 Years Old
Name
Your answer
Parent/Guardian E-Signature if 16 or 17 Years Old
By e-signing below and submitting this application I affirm that the facts set forth in it are true and complete. I give my consent to the above mentioned minor to volunteer with ICNA Relief USA Programs Inc. I also give my consent to ICNA Relief USA Programs Inc. to add my information to the online database for future use. I understand that if accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me or the above mentioned minor on this application may result in immediate dismissal.
Your answer
Special Skills / Qualifications
Disabilities / Illness
Your answer
Phone
Your answer
Email
Your answer
Address
Your answer
Media Release *
Required
Release of Liabilities *
Required
In Case of Emergency Please Notify
Name
Your answer
Agreement and Signature *
By e-signing below and submitting this application I affirm that the facts set forth in it are true and complete. I give my consent to ICNA Relief USA Programs Inc. to add my information to the online database for future use. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Your answer
Our Policy
It is the policy of this organization to provide equal opportunities regardless of race, color, religion, national origin, gender, age, or disability.
Thank you for completing this application form and for your interest in volunteering with ICNA Relief USA, Disaster Response Services. We pray that Allah SWT (Almighty God, in Arabic) continue to bless our efforts, for the benefit of our souls and for the benefit of those whom we serve.
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