iCARE 2018 Vision Project Application and Intake Form
First Name (Nickname or name you prefer to be called) *
This is the name that will appear on your name tag
Your answer
Last Name *
Your answer
Which Week Are You Applying: *
Required
Your Profession: *
Your answer
Email: *
Please note, if you are filling out an application for yourself and a family member or friend PLEASE provide your own individual email address for each application. We CAN NOT send multiple DocuSign packets (volunteer paperwork) to one email address.
Your answer
Please provide an alternate email address in case of technical difficulties: *
Occassionally, we have technical challenges with DocuSign (especially with university emails) so it's helpful to have a 2nd email on file if you have one. If you don't have an alternate email please write N/a below.
Your answer
What is the best phone number to call to reach you *
Work Number *
Ex: 000-000-0000
Your answer
Cell Phone Number *
Ex: 000-000-0000
Your answer
Home Phone Number *
Ex: 000-000-0000
Your answer
Gender: *
Birth Date: *
(MM/DD/YYYY)
MM
/
DD
/
YYYY
Home Address: *
Your answer
City: *
Your answer
State/Province: *
Your answer
Zipcode/Postal Code: *
Your answer
Work Address: *
Your answer
City: *
Your answer
State/Province: *
Your answer
Zipcode/Postal Code: *
Your answer
T-Shirt Size *
Full Name (as it appears on your passport) *
Your answer
Passport Issued in (Country): *
Your answer
Passport #: *
Your answer
Passport Expiration Date: *
(DD/MM/YYYY; at least 6 months remaining on day of departure)
MM
/
DD
/
YYYY
Including this year, how many years have you volunteered on the project? *
(Ex: If this is your first year volunteering you would write 1, if this is your second volunteering 2)
Your answer
If this is your first year volunteering, how did you hear about us? *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Relationship: *
Spouse, Mother, Father, Sister, Brother, Aunt, Uncle, etc.
Your answer
Emergency Contact Phone Number: *
Your answer
Serious Medical Conditions/Medications/Allergies we should be aware of In Case of Emergency: *
Your answer
Experience on International Missions and/or Eye Care Work? *
Your answer
Are you coming with anyone else? Please list names of other persons in your group: *
Your answer
Roomate Preferences *
As you know, there may be as many as 3 persons to a room on our project. Private room options are available for an additional project fee, if available.
Required
If you have roommates, please list their names: *
If you don't have roommates please type "None" in the box below.
Your answer
If you don't have roommates, what is your General Bed Time: *
Required
Other Concerns Regarding Roommates:
Your answer
General Requests or Concerns:
Your answer
Due to possible technical issues, please email tiffany@greatshapeinc.org AFTER you click submit to be sure she received your application. *
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