iCARE 2023 Vision Project Application and Intake Form
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First Name (Nickname or name you prefer to be called) *
This is the name that will appear on your name tag
Last Name *
Which Week(s) Are You Applying (you may select all that apply): *
Required
Your Profession: *
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.
Please provide an alternate email address in case of technical difficulties: *
If you don't have an alternate email please write N/a below.
What is the best phone number to call to reach you *
Work Number *
Ex: 000-000-0000 (please use hyphens)
Cell Phone Number *
Ex: 000-000-0000 (please use hyphens)
Home Phone Number *
Ex: 000-000-0000 (please use hyphens)
Gender Identification (For Room Assignments Only) *
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: *
City: *
State/Province: *
Zipcode/Postal Code: *
Work Address: *
City: *
State/Province: *
Zipcode/Postal Code: *
T-Shirt Size *
Full Name (as it appears on your passport) *
Passport Issued in (Country): *
Passport #: *
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)
How did you hear about us? *
Please tell us how you found out about us. Please be specific if it is via a person or organization.
Emergency Contact Name: *
Emergency Contact Relationship: *
Spouse, Mother, Father, Sister, Brother, Aunt, Uncle, etc.
Emergency Contact Phone Number: *
Ex: 000-000-0000 (please use hyphens)
Serious Medical Conditions/Medications/Allergies we should be aware of In Case of Emergency: *
Experience on International Missions and/or Eye Care Work? *
Are you coming with anyone else? Please list names of other persons in your group: *
Roomate Preferences *
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.
Will you be joining our project as a couple? If so, please provide the name of your significant other. If not, type N/a: *
If joining the project as a couple, please provide the name of your significant other: *
If Couples: 3rd project fee or bringing someone else *
If you prefer to have your privacy and the space is available, you may 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:
General Requests or Concerns:
IMPORTANT: PLEASE ENSURE YOU GET A CONFIRMATION MESSAGE AT COMPLETION. IF YOU DON'T GET ONE, YOUR APPLICATION HAS NOT BEEN SENT AND YOU LIKELY HAVE ONE OR MORE INCOMPLETE RESPONSES TO FIX BEFORE TRYING AGAIN. We will send an email confirming receipt of your application within a week, but if you don't hear from us you can confirm receipt of your application by emailing: support@greatshapeinc.org  *
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