Shades of Green Volunteer Survey

Thank you for volunteering for the Shades of Green event on Saturday, October 28th at the America's Center. Volunteers are vital to the success of this event and we truly appreciate all the volunteer help provided. For any questions, please contact Nicole Dalton at 314.592.2312 or ndalton@girlscoutsem.org.

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* 1. Please provide your contact information:

Name

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. Are you part of a volunteer group?

Yes

If yes, please list name of group (ex. University group, Organizational group, Community Service group, etc.):

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* 3. Have you been recruited to serve in a specific capacity?

Yes

If yes, what role will you be fulfilling?

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* 4. Please indicate your availability:

Early shift 9am-2pm

Late shift 1pm-6:30pm

Full day 9am-6:30pm

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* 5. Racial Ethnic Background

White

Black

Asian

Hawaiian/Pacific Islander

American Indian/Alaskan Native

Also Hispanic

Other

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* 6. Disability Information: Girl Scouts of Eastern Missouri welcomes the participation of all girls and adults and will make reasonable accommodations for persons with disabilities. To help Girl Scouts of Eastern Missouri better serve you, please indicate whether you need a reasonable accommodation in order to fully participate in the program. The External Collaborations Coordinator will contact you to answer questions and discuss accommodations requests. Do you need a reasonable accommodation?

Yes

Describe the accommodation request:

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* 7. Media Permission: I agree to grant Girl Scouts of Eastern Missouri a perpetual, royalty-free, transferable license to use my name, likeness, image and voice and to use any material I provide to Girl Scouts of Eastern Missouri to promote or advetise its mission and will not be offered for sale or consideration. I also agree to release and hold harmless Girl Scouts of Eastern Missouri and its designated directors, officers,employees agents and affiliated agencies in all matters concerning this release and license.

I wish to opt out at this time.