Individual Volunteer Form Date Are you volunteering with a group? Yes No If Yes, What Is The Group Or Organization Name? TELL US ABOUT YOURSELF Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone* Email* Would you prefer to be added to our mailing list?* Yes No Parent Information (if required) Are you under 18?* Yes No If you are under 18, please provide Parents Name and Parents Phone Number TELL US ABOUT YOUR EXPERIENCE Do you have prior volunteer experience? Yes No If yes, please describe: Are you fulfilling a school/Mitzvah requirement? Yes No What days are you available to volunteer? Sunday Monday Tuesday Wednesday Thursday Friday Saturday What hours are you available to volunteer? 10am – 12pm 12pm – 2pm 2pm – 4pm How did you hear about Afya? If possible, please provide a list of participants. In connection with my volunteer activities at and for The Afya Foundation of America, Inc., a non-profit charitable organization (“Afya”), I hereby agree, for myself, my heirs, assigns, executor and administrators to release and discharge Afya, its officers and directors, affiliates, employees, agents and volunteers from all claims, demands, and actions for injuries, losses or damages of any kind sustained or suffered by me or to my person and/or property as a result of my involvement in such activities, whether or not resulting from negligence of any party, and I agree to release and hold Afya, its officer and directors, affiliates, employees, agents and volunteers harmless from any cause or action, claim, suit or loss or damage of any kind arising therefrom. I agree to grant Afya the right to use my name and image in all forms and media. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at my own risk, and that I have read the foregoing terms and conditions of this release.