Baton Rouge Regional Eye Bank  

(225) 766-8996
Fax:(225) 765-4366

7777 Hennessy Blvd, Suite 1005
Baton Rouge, Louisiana 70808

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Baton Rouge Eye Bank
Eye Donor Successes
Eye Bank Volunteers
About Eyes
FAQ's about the Eye Bank
About the Eye Bank

Membership & Membership Renewal Form

State: Zip Code:
Phone
Office: Cell:
Date of Birth:
Areas of Interest

Phantom Breakfast Fundraiser

Day at the Races Fundraiser

Thanksgiving Memorial Service for Life and Sight

Future Events

Distribute Brochures - Offices, Hospitals

Health Fairs - Schools, Churches, Hospitals

Guest Speaker

Have you ever been convicted of a felony?

If yes, explain:

Do you have any physical or mental limitations that would affect your ability to perform the functions of this position?
Yes No
If yes, explain:

Reference
State: Zip Code:
Alternate Phone:
Emergency Contact
State: Zip Code:
Alternate Phone:
Relationship:
Type code for security:

Application Information Certification

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.  I certify that the answers given to the foregoing statements are correct and without omission.  I authorize Baton Rouge Regional Eye Bank to investigate the foregoing.  If upon investigation, anything contained in this application is found to be untrue, I understand I will be subject to dismissal at any time during the period of volunteering.  Your signature indicates you approval for us to check references.  I also understand I will not be paid for my service.  I certify the above is true to the best of my knowledge.

Digital Signature:

 

 
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