Name *

First Name

Last Name

Phone *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Emergency Contact Phone *

(###)

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I am interested in volunteering during... *

Week 1 (June 9-13)

Week 2 (June 16-20)

Week 3 (June 23-27)

Health Insurance and Workers’ Compensation Coverage Acknowledgement: *

I understand and acknowledge that NUMU does not offer or provide health insurance or Workers’ Compensation coverage and should I incur an injury, either onsite or offsite, during a volunteer assignment I am fully responsible for my medical care. Volunteers that are under the age of 18 require a parent or guardian's signature on this application. Your signature is required for your volunteer application to be accepted.