Volunteer Registration Form
Host name: Autism Society of Nebraska & Pediatric Therapy Center
Camp dates: July 26, 2021 - July 30, 2021
Camp location/address: BPS Lied Activity Center, 2700 Arboretum Dr, Bellevue, NE 68005

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 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.
If you are under 15, please contact the Camp Host for possible opportunities.

For questions please contact Julie Czepa at icanbikeomaha@autismnebraska.org
Volunteer First Name *
Volunteer Last Name *
Gender
Clear selection
Date of Birth *
MM
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DD
/
YYYY
This question is intentionally left blank
E-mail address *
Please ensure you have entered a valid email. The Camp Host will use this address when corresponding with you.
Cell Phone *
Please enter 10 digits
Home Address (Number and Street) *
Home Address (City) *
Home Address (Zip Code) *
5 digits only, please. e.g., 22011
Home Address State/Province *
Emergency Contact Name *
Emergency Contact Phone *
Enter 10 digits only, please. e.g., 3031112222
Parent/Guardian Email (if volunteer is under 18 y/o)
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