University of Nevada Cooperative Extension
VOLUNTEER APPLICATION
Master Gardener Training

September 11th - October 11th, 2001
Tuesday, Wednesday, Thursday, 6:30 p.m. - 9:30 p.m.
Humboldt County Extension Office, 1085 Fairgrounds Road
Winnemucca, NV 89445 (775) 623.6304

___________________________________________________________________________________________________________________________________________ 
(Last Name)                                                                  (First Name)                                                                     (Name you would like on your badge)
Mailing Address: _________________________________________
                         _________________________________________
                        (include number, street, city, state, zip)
Email Address: ________________________________________________
Home Phone: _________________________________________________     Work Phone: ___________________________________________________________
Social Security Number: _____-_____-_____ (for university record keeping)                                         T-Shirt Size: ____________________
Occupation: ____________________________________________________________________________________________________________________________
                                     (if retired, what was your occupation?)
Is it neccessary for you to limit your physical activity in any way? ________Yes ________No
If Yes, what is your limitation? _____________________________________________________________________________________________________________
Please list any previous experiences (volunteer, paid or educational) that would be helpful in working with people:
ACTIVITY                                                               ORGANIZATION                                                                         DATE
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
List any skills, hobbies, or interests you have that might be helpful in your volunteer work:
__________________________________________________________________________________________________________________________________________
Please tell us why you would like to become a University of Nevada, Cooperative Extension Master Gardener Volunteer:
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
What kind of volunteering would you like to participate in?
__________________________________________________________________________________________________________________________________________
Do you speak/read/write any language in addition to English? _____Yes _____No
If yes, what other language(s)? ________________________________________________________________________________________________________________
Please give the name of any person who should be notified in the event of an emergency:
Name: __________________________________________     Phone: _________________________________________
Address: ___________________________________________________________________________________________________
I understand that the above information is voluntarily supplied and may be used and disclosed for University of Nevada Cooperative Extension, that as a Cooperative Extension volunteer I will not be paid for my services, and that I agree to volunteer 40 hours community service within a year of completing my training.

__________________________________________________________
Signature                                                          Date

Please make checks payable to Board of Regents and return this form along with a $100 payment to: Humboldt County Extension Office, 1085 Fairground Road, Winnemucca, NV 89445 by August 20, 2001. Registration fee covers materials, refreshments, luncheon, badge and t-shirt.