Healthy Peninsula Volunteer Contact and Agreement
Thank you for your interest in volunteering with Healthy Peninsula!  There are many ways for you to be involved.  Please review and complete the following form, returning to Suzie Nutbrown: snutbrown@healthypeninsula.org.  
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Volunteer's Full Name *
Date of Birth *
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Race (optional)
Gender (optional)
Pronouns (optional)
Email
Phone *
Cell Phone
Mailing Address
What is your preferred way to communicate?
Please tell us a little about yourself - what are your skills, experiences, languages and hobbies? *
How did you hear about Healthy Peninsula? *
How are you interested in helping out? *
Required
How often would you like to volunteer? *
Have you ever had a background check? *
Do you give permission for us to conduct a background check? *
Do you have a valid driver's license? *
Please share your driver's license number - including the state in which it was issued: *
When does your driver's license expire? *
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What is the name of your automobile insurance company and your policy number? *
When does your automobile insurance expire? *
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Have you ever been convicted for violation of any laws, traffic or otherwise?  If yes, please explain below. *
Do you have any physical condition that may limit your volunteer activities?  *
Please share information on any physical condition that may limit your volunteer activities.
Please share the name and phone number for an emergency contact: *
By entering your full name below, you are giving Healthy Peninsula permission to conduct a background check (for drivers this may include a drivers' record check).

Thank you!
 *
Public Media Release Statement
By entering your full name below, you agree to allow Healthy Peninsula to use your name, likeness (photo) or audio for public relations materials, including but not limited to, posting on Healthy Peninsula's website, posting on FaceBook pages, newspapers and television advertisements or public service announcements, brochures or flyers.  HP retains sole copyright to said likeness and may use it in any form now and in the future.  Signing this statement, you understand that you will receive no monetary gain from this use.
Please enter date this form was completed. *
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Please contact Suzie Nutbrown at snutbrown@healthypeninsula.org if you have any questions.  We look forward to talking with you soon!
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