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Baton Rouge Regional Eye Bank
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Become a Member
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
*
MM slash DD slash YYYY
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?
*
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
*
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