Become a Member – Baton Rouge Regional Eye Bank

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Home Phone

Work Phone

Cell Phone

Date of Birth*

Areas of Interest*

Have you ever been convicted of a felony?*

Yes
No

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 Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Emergency Contact Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Relationship*

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*