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This portion of the form to be filled out by the Volunteer:
Social Security No: _____________________ Last Name: ________________________ First Name:____________________________Middle Name:_____________________ Preferred First Name:___________________Date of Birth: ______________________ Gender: ο Female ο Male |
Permanent Address: _______________________________________________
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Medical Insurance Carrier: (Optional)________________________________________________
EMERGENCY CONTACT INFORMATION: Contact Last Name: _____________________ First: ____________________Middle:_______________ Relationship_______________________ Address: Street: ______________________________City: _________________State:______ Zip: ___________ Phone:( ____ ) -____________Ext:_________________ |
I have carefully read the Canisius College Volunteer Policy and information above and understand their contents. The above information provided by me is accurate.
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This portion of the form is to be filled out by the department supervisor:
Department Head | Title | Email Address |
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Unit | Telephone Number | Begin and End Dates |
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Description of Volunteer Duties:
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Witness____________________________________ Date______________________________
