Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Skills, Experience & Qualifications

Please check any that apply

Physician

Oncologist

Nurse Practitioner

Social Worker

Mountaineer

Military

What dates are you signing up for?

From

MM

DD

YYYY

until

MM

DD

YYYY

I authorize See You At The Summit to conduct an investigative consumer report in an effort to place me into a volunteer position.

See You At The Summit may request consumer reports, as defined by the federal Fair Credit Reporting Act, on you from a consumer reporting agency in connection with your volunteering application and for volunteering purposes. A consumer report is a compilation of information that might affect your ability to volunteer for the Company. These reports may contain information about your character, general reputation, personal characteristics and mode of living. The reports may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, education or employment history, or other background checks.

Yes

No

I agree that I will not take any photos of minors on any personal device unless given express permission by See You At The Summit executive director, Heather Rose Otto *

Agree

Disagree

I agree that I will not exchange any personal information with any minors such as phone numbers, addresses, etc. *

Agree

Disagree

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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