iCARE 2019 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 (if you are associated with a school (student/faculty) please provide your personal email address. You can provide your school address as an alternate) *
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: *
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) Be sure to type this date in. Please don't use the drop down arrow because it auto defaults to the current year.
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. Be sure to type this date in. Please don't use the drop down arrow because it auto defaults to the current year. )
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? *
Please provide us with the specific name of volunteer, group, publication or other method that you found out about us through.
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
Will you be joining our project as a couple? If so, please provide the name of your significant other: *
Your answer
If Couples: 3rd project fee or bringing someone else *
If you would prefer to have your privacy, if space allows and is approved, you can pay a 3rd project fee to guarantee a room for two. Please let us know which of these statements best describes your rooming situation
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
We will send an email confirming receipt of your application, but if you don't hear from us by the close of the business day that you applied (except for weekends - we'll send a receipt the following Monday) you can confirm receipt of your application by emailing: leana@greatshapeinc.org *
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