|
University of Nevada
Cooperative Extension |
| ___________________________________________________________________________________________________________________________________________ (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.
__________________________________________________________ |
| 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. |