Name    

Address

City        

State      

Zip          

Phone     

Date of Birth

Gender: Male Female

E-mail  

Are you a Niagara University Employee?   Yes    No

Are you a Veteran?     Yes      No

How did you learn about Border Community SERVICE at Niagara University?

Physical/Medical Limitations:

Emergency Contact:

Name

Phone:

As a participant in this grant project you will be automatically covered by volunteer insurance coverage.  Please provide the following information.

Do you expect to use your own vehicle for any Border Community SERVICE volunteer activities?   Yes   No

Beneficiary for Volunteer Supplemental Accident Insurance which will be provided free of charge:

Name:    

Relationship         

Address              

City              

State           Zip

Phone  

I acknowledge that by participating in this training, I am making a commitment to provide volunteer services through Border Community SERVICE in the event of an emergency.

Signature    
  Date     

Image verification Code

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