Climb For A Cause Dental Relief Projects
Volunteer Service Application
Please print, then complete
this application and either fax it to us at 312-455-9491 or mail to: 1512
Required Non-Refundable Deposit
is $500: If you prefer to send your Deposit by check, please make your Check
payable to Climb For A Cause and place appropriate Event in the memo section of
your check.
SERVICE PROJECT NAME: Climb For A Cause
POSITION APPLIED FOR:_________________________________________________
(e.g. Lay Person / Medical Assistant / Doctor-Dentist)
*If you are applying as a Medical Professional, would you accept a general volunteer position if the position you are applying for has already been filled: YES______ NO______
DEPARTURE DATE___________________________________________________________________
PERSONAL INFORMATION
Name_________________________________________________________________________________
(Last
Name) (First
Name)
Address_______________________________________________________________________________
(Street #)
Address_______________________________________________________________________________
(City) (State) (Zip)
Telephone: Home____________________________ Business___________________________________
E-mail Address__________________________________ Fax Number_____________________________
Occupation ____________________________________________________________________________
Date of Birth_____________________________________ Nationality ____________________________
(DD/MM/YYYY)
Passport No._____________________________________ Exp. Date______________________________
Date of
Credit Card No. __________________________________________ Expiration _____________________
Card verification _______________ Card Billing Address ________________________________
(3 digits)
Signature ____________________________________________ Date _________________