VITA | Volunteer Application

First Name *

Last Name

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Preferred method of contact?PhoneEmail

Have you previously volunteered for VITA? *YesNo

Do you have previous tax preparation experience? *YesNo

Please describe your previous experience

Do you have bilingual skills?YesNo

What languages do you speak?

Hours available to volunteer: *

Monday 12:30 - 3:30 p.m.Monday 3:30 - 6:00 p.m.Tuesday 5:00 - 8:00 p.m.Wednesday 12:30 - 3:30 p.m.Wednesday 3:30 - 6:00 p.m.Thursday 12:30 - 3:30 p.m.Thursday 3:30 - 6:00 p.m.Saturday 8:00 a.m. - 12:00 p.m.(check all that apply)

How many hours per week would you like to volunteer for VITA?

I am willing to provide the following type of service:

In-person (taxpayer contact)Virtual (on-site)Virtual (at home)check all that apply

Please explain:

Emergency Contact information

First Name *

Last Name

Relationship *

Phone *

Do any of your relatives work for Goodwill NCWYesNo

have you ever been convicted of a crime? *YesNo

Name of relative?

Please explain:

Medical Consent

Medical Authorization *

YesBy checking the box below, I authorize the sponsoring VITA agency to provide first aid to me as may be necessary. I also give my permission to be transported to a local hospital for necessary medical treatment.

Signature & Acknowledgement

By entering my full name in the space below, I am consenting to the above items, and confirming the accuracy of the information provided. I hereby grant Goodwill NCW the right and permission to use my name in connection with the photograph, video, recording or other likeness if it so chooses. If applicable, I also grant Goodwill NCW the right to use any name, mark or logo whether or not registered, in any manner consistent with the balance of this authorization and consent. I hereby grant permission to Goodwill NCW to put the finished pictures, digital files, reproductions and copies of the originals of me/the Minor, including the right to substitute the voice of other persons for my/the Minor’s likeness (collectively “Tangible and Intangible Items”), in any legal use. I hereby grant Goodwill NCW permission to use said Tangible and Intangible Items in any manner deemed proper by Goodwill NCW so long as such use is in connection with the exhibition, advertising, promotion, distribution and/or other purpose for the service or trade of Goodwill products, services or programs. This consent shall remain in effect indefinitely, unless I revoke it. I understand that I may revoke this authorization by submitting a written request to the Marketing Team, Goodwill NCW, 1800 Appleton Road, Menasha, WI 54952. I understand that, if I revoke this authorization, my revocation will not have any effect on actions already taken by Goodwill NCW in reliance on my authorization. I will not disaffirm or disavow this consent and permission on the ground that I/the Minor was unable to enter a binding contract on the date of execution hereof or any similar grounds whatsoever, or endeavor to recover from Goodwill NCW or any of its member organizations, any sums for being depicted in any video, photograph, recording or other likeness. By entering your name, you are digitally signing this form indicating that you have read and understood the above release form.

First Name *

Last Name

Date *