Date

How did you hear about us?

Name

Email Address

Street Address

Telephone

Birth Date

Language(s) spoken other than English?

Tell us about your skills and interests that you like to share?

What type of volunteering would you like to do? What type of volunteering would you like to do? Driver (to activities, appointments, shopping) Volunteer in school - assisting student/teacher - English language instruction Volunteer in home - English language instruction Medical - arranging appointments, dentist, doctors, vaccination clinic Assisting with completing government forms, grant applications Office Assistant - note taking, transcripts, letter writing Translator Board and Committees Other

When are you available to help? Please indicate week and/or weekend.

Do you have any health restriction (yes/no). If yes, please explain.

If you are placed as a volunteer, do you commit to the following volunteer responsibilities related to the volunteer role within Ukraine Nightingale Project? Please respond by a check in the boxes: If you are placed as a volunteer, do you commit to the following volunteer responsibilities related to the volunteer role within Ukraine Nightingale Project? Please respond by a check in the boxes: • Carry out the duties to the best of your ability • Maintain the confidentiality of internal and personal information of the individual family • Accept the guidance and decisions of the of the Directors • Act in accordance with Nightingale values and code of conduct • Report all incidents to the Directors of the Nightingale Project

Please provide with the name and telephone number of two references, not related to you, who can vouch for your ability to volunteer with us.

I consent to the Ukraine Nightingale Project, using the personal information supplied above to inform me about, programs, services and events. I consent to the Ukraine Nightingale Project, using the personal information supplied above to inform me about, programs, services and events. Yes