Volunteer Registration Form

* = required field

Volunteer Information

 
* First Name:
* Last Name:
* Name as you would like it to appear on nametag:
* Date of Birth:    
Gender:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
Zip:
Phone:
* Email:
Parent Name (if under 18):
Parent Phone (if under 18):
* Emergency Contact Name:
* Emergency Contact Phone:
If with a school/organization, please specify:
Former Special Needs Skills/Training :
(please check all that apply)






If Healthcare Professional, then what field:
If other, please explain:
I Have Volunteered at Night to Shine Before:



Volunteer Role Requested:
(we will consider your request but cannot guarantee a specific role)
Buddies are requested to wear a Night to Shine t-shirt. The cost will be $6. We will have these ready for pick up at the training meeting and you can pay there. Please select your t-shirt size.
Additional Notes or Concerns: