First Name *

Last Name *

Email *

Phone *

Address 1

City

State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip

How did you hear about us? *

Please list any KU MSAC staff, volunteers, or members that you know

Hobbies/ Interests

What inspired you to volunteer at the KU MSAC? *

Previous volunteer experience *

Special skills/ interests

What 3 adjectives describe you?

Please list any special accommodations needed to volunteer with us

Emergency Contact Name

Emergency Contact Phone

Relationship

I am interested in: *

I am available on these days of the week:

I am available these hours of the day:

Non-Family Reference Name *

Non-Family Reference phone *

Non-Family Reference email

I understand KU MSAC does not guarantee volunteer placement and that volunteer activities may or may not include interaction with members.

I agree to be added to the mailing list for future volunteer opportunities.

Signature (please type full name) *

Date *