Volunteer Interest Survey

Xeroderma Pigmentosum Society, Inc.
437 Snydertown Road
Craryville, N.Y. 12521 USA

Voice/Fax (518) 851 - 9490

Last Name:__________________________ First Name:_____________________________

Street Address: __________________________________________________________________

City: ___________________________________ State: _________ Zip: __________________

Age:____ Male__ Female__  Telephone(work)_________________ (home)_________________

In Case of Emergency contact:

Last Name: __________________________  First Name: _______________________________

Telephone: ___________________  Relationship to you: _____________________________

Occupation or Work Experience: ___________________________________________________

*Employer: _______________________________________________________________________

 Address: ________________________________________________________________________
*If less then 3 years please attach an additional sheet.
May we contact your employer? ___Yes ___No.             Do you drive? ___Yes ___No

Education Completed: ___High School  ____Years of College  ____ Graduate School

Field of study:___________________________________________________________________
Hobbies/Interests: _______________________________________________________________
 
How did you find out about the XP Society?
___Friend ___Newspaper/Media ___Other(please explain)_____________________________

I am interested in helping out in one or more of the following areas checked below:
__ Camp Sundown  __Publicity     Other(please explain)_____________________________
   __ Crafts     __ Office Work          __________________________________________
   __ Cleaning   __ Fund Raising         __________________________________________
   __ Cooking

Times you are available: ______Mornings  _______Evenings  _____Nights 
                         ______Weekdays  _______Weekends  _____When Needed
Personal References:
                              
Name: _________________________________  Address: ____________________________

Phone: ____________________                       ____________________________

Name: _________________________________  Address: ____________________________

Phone: ____________________                       ____________________________  

Date: _____________________  Signature: ______________________________________