Step 1 of 3 33% Contact InformationName* First Last Email* Mobile PhoneHome PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact:* Email Phone Mail About MeI am a:*Donor FamilyCornea RecipientHealthcare ProfessionalCommunity MemberI am:EmployedRetiredA studentOtherPresent Occupation: How did you hear about our volunteer program?*Please list two references:*NamePhone number Special Skills/Training:* Hobbies/Interests:* List any languages, other than English, which you speak fluently: Do you have any privious volunteer experience? If so, when and with which organizations have you worked?*I am interested in:* Public Speaking Event Support Art Submissions Sharing My Story Social Media Action Other In case of emergency, please notify:*NamePhone Please read and consent to the following:Saving Sight Volunteer Code of Conduct* I agree to the Saving Sight volunteer code of conduct.I understand that any pattern of conduct that would tend to disrupt, diminish, or otherwise jeopardize public/client trust in Saving Sight will result in immediate dismissal. I understand that my volunteer assignment with Saving Sight may be terminated at any time. Saving Sight Liability Policy* I agree to the Saving Sight Liability Policy.In consideration of Saving Sight allowing the me to participate in volunteer programs, and being aware of the possible injuries that could occur as a result of that participation, I, on behalf of myself release Saving Sight, employees, agent, instructors from any and all injuries and damages whatsoever from participating in events. I, my heirs, and representative, agree to indemnify, save, and hold harmless Saving Sight, its officials, employees, and agents from any and all claims made by me or my insurer for injuries or damages related to these events. Saving Sight Likeness Release* I agree to the Saving Sight Likeness Release:The undersigned hereby irrevocably consents to and authorizes the use by Saving Sight, its officers and employees, of the undersigned’s image, voice, likeness and/or story as follows: Saving Sight shall have the right to photograph, publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse the undersigned’s image, voice, likeness, and/or story in connection with any product, service, or program in all markets, media, or technology now known or hereafter developed in Saving Sight’s products, services or program for the promotion of Saving Sight’s programs, as long as there is no intent to use the image, voice, likeness, and/or story in a disparaging manner. Saving Sight may exercise any of these rights itself or through any successors, transferees, licensees, distributors, or other parties, commercial or nonprofit. The undersigned acknowledges receipt of good and valuable consideration in exchange for this Release, which may simply be the opportunity to represent Saving Sight in its promotional and advertising materials as described above. The undersigned understands likenesses captured may be used as stated herein for an indefinite period.Full Name* First Date* Month Day Year Untitled First Choice Second Choice Third Choice NameThis field is for validation purposes and should be left unchanged.