Bridging Bionics

Volunteer

Name:

Age:

Date of Birth:

Address:

Home phone:

Cell phone:

Email address:

Gender

Male

Female

Height:

Weight: lbs.

Primary language spoken/understood:

Other languages spoken/understood:

Have you worked with people with disabilities?

Yes

If yes, please describe your experience:

Do you have any First Aid training?

Yes

If yes, please describe:

Volunteering for our program can be physically demanding and may require lifting equipment and assisting with lifting clients to help them transfer into the equipment.

Do you have any physical limitations?

Yes

If yes, please describe:

Can you lift more than 50 lbs?

Yes

Do you have cognitive challenges that we need to consider when assisting clients?

Yes

If yes, please describe:

Emergency Contact Information

(if different from Parent/Guardian)

Name:

Relation:

Home phone:

Cell phone:

Work phone:

Primary language spoken/understood:

Volunteer Application

Volunteer

Emergency Contact Information