2017-2018 VISTA Members: Personal Information Form

Welcome to Campus Compact of Oregon!

Welcome to the Campus Compact of Oregon VISTA Program! We're so excited to have you join the team. This survey is confidential and will only be shared with Campus Compact of Oregon staff.

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* 1. Where will you be serving?

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* 2. Member Contact Information

Full Name

Address*

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address**

Phone Number

*ADDRESS CHANGE: Please notify Campus Compact of Oregon and update your AmeriCorps account when your address changes.

**EMAIL IMPORTANT: Please list the email address that you will continue to use throughout your service year. Your paystubs and all Campus Compact communication will be sent to this email address. If you're a student, we suggest using a personal account rather than school account. Let us know if your email address changes as any time.

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* 3. About You!

Full name you'd like on your name tag (Ex. Mila Buckland)

Preferred Pronouns (she, her, hers)

T-Shirt Size

Sweatshirt Size

Food Accommodations

Allergies

Can staff text you for service related questions?

Will you be relocating to serve?

If you are relocating, how will you get to the VISTA Pre-Orientation? (Plane, Car, etc.)

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* 4. Emergency Contact 1

Relationship

Phone Number

Address

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* 5. Emergency Contact 2

Relationship

Phone Number

Address

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* 6. Health Insurance Information

Health Insurance Company

Member ID

Group Number

Phone Number

Preferred Emergency Medical Care Site

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* 7. Campus Compact of Oregon, in an effort to cut down costs as well as environmental impact, helps arrange a carpool amongst members to required trainings and events (like our three in-service trainings). Members are only reimbursed if they are willing to participate in the carpool and drive other members (and Campus Compact attempts to only place members in your area in your car) unless special permission is given by your program manager or if you are placed at a location where no one other member is around. Additionally, drivers are rotated for fairness amongst programs. Please select what is true for you below.

I have a valid Driver's license, my own vehicle, and am willing to be either a Driver or passenger as needed!

I have a valid Driver's license, my own vehicle, and am only willing to be a Driver. Otherwise, I forfeit my ability to be reimbursed.

I have a valid Driver's license, but do not have my own vehicle and need/prefer a ride.

I do not have a valid Driver's license, do not have my own vehicle and need a ride.

I have a valid Driver's license, have my own vehicle but only want to drive myself, therefore forfeiting my ability to be reimbursed.

I'm not sure yet and need further conversation.