Student Volunteer Application "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Student Volunteer InformationName* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(s)* Home Cell Home PhoneCellphoneEmail Address* Birth date* DD slash MM slash YYYY Grade level (volunteers under the age of 16 must be accompanied by an adult)SchoolDo you need a letter or email confirming your volunteer service? Yes No If yes, what is the name/address of recipient of confirmation:Type your name to sign*Date* MM slash DD slash YYYY Guardian Information (required for volunteers under the age of 18)Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(s)* Home Cell PhoneEmail Relationship to Volunteer:Authorization by Guardian (required for volunteers under the age of 18)I, hereby grant permission for a duly authorized representative of Surrey Services for Seniors to conduct information checks for my background. Type Guardian's name to sign*Date* MM slash DD slash YYYY Indemnification ClauseI hereby exonerate and hold harmless Surrey Services, its officers, directors, employees, volunteers, agents and designees from any and all injuries (including death) that may occur as a result of, or during my participation in volunteer activities for Surrey Services.Type Guardian's name to sign*Date* MM slash DD slash YYYY Photo Release ClauseI grant Surrey Services permission to publish photographs of me taken during my participation in volunteer activities. I understand that these images may be published in any manner, including advertising, periodicals, greeting cards, calendars and on the Surrey website. Said photos will be used expressly for the objective of educating the public about Surrey and volunteerism.Type Guardian's name to sign*Date* MM slash DD slash YYYY
