Volunteer Data Form

Please print, fill out, and mail
your completed Volunteer Data Form to (at the moment you cannot submit it online):
Mission Volunteers Office, GBGM, 475 Riverside Drive, Suite 330, New York, NY 10115.  Thanks!

By checking this box and /or by my signature below, I consent to the recording and use of the personal data I am providing for the Mission Volunteers Database (MVDB), utilized by designated, password-authorized persons in GBGM, UM Committee on Relief (UMCOR), UM Volunteers In Mission (UMVIM), and MV programs. A voluntary service, the MVDB provides information for volunteer recruitment, placement, and communication, as well as insurance and statistical record-keeping. I may obtain a copy of and/or request the deletion of my data by contacting GBGM by signatured request. After seven (7) years of no data activity, my personal data may be deleted. I release GBGM and all MVDB-authorized users from all legal responsibility for the use of my personal data unless they have recklessly misused the information. For complete details regarding MVDB policies, please consult: http://gbgm-umc.org/vim/mvdb/policy.htm.

Other:  Legal/Passport 
Name   First Name M.I. Last Name
Nickname/Preferred  Passport Number # Expiration Date   (M/D/Y) DoB (M/D/Y)
Occupation: Citizenship: 
Local Church:  Church Phone #:
United Methodist Conference:

What types of experience have you had?    Local    National    International

What is/are your geographical preference(s) for future missions/placements?LocalNationalInternational
I can be contacted if my skills might be needed.yes-anytimeyes-week's noticeyes-month's noticeno

Emergency Contact
Primary   Full Name    EC Relationship  EC Phone#  
Emergency Contact
Alternate   Full Name  (alternate)  EC Relationship  EC Phone#  

                                                                                                                                 
I would like Newsletters.    UM Volunteers In Mission        The Knock-UMF/Health Care Volunteers

Current Address
Home Address:   Street    City    State Country/Region  Postal Code
Home Phone:  Mobil Phone: 
FAX#      E-Mail Address:
Work Address
Home Address:   Street    City    State Country/Region  Postal Code
Work Phone:  Mobil Phone: 
FAX#      E-Mail Address:

Interests /Memberships  Please check all of the appropriate boxes for the following questions /statements.
How many Volunteer In Mission Experiences have you had in the past 10 years?
How many VIM Team Leader Experiences have you had in the past 10 years?     Number:

I am interested (INT) in or a (M/P) member /Participant of the following programs:

INT M/P
Individual Volunteer (Commitment  - 2+ months)
United Methodist Fellowship of Health Care Volunteers (UMF/HCV) Date Joined: (m/d/y)
Disaster Response.  If member, last UMCOR Training: (m/d/y)
Level I: Early Response  Basic Training Academy
Level II: Pastoral Care   Case Management Volunteer Management
Warehouse   Children Youth Older Adults
NOMADS    (program for volunteers with recreational vehicles)
Global Justice Volunteers (a social justice program for young adults 18 - 25)
Primetimers (a learning and service experience for adults are 50+)

Languages                      

Spoken Fluent Intermediate Beginner
English
Spanish
French
Portuguese
German
Russian
Other
Other

General Skills

A/V Specialist Drawing/Planning Managing/Administrating Semi-Truck Driver
Agriculture ESL Education Manufacturing Sewing
Animal Husbandry Farming Mechanics (Auto) Singing/Braille
Architecture Finance/Accounting Mechanics (General) Social Work
Broadcasting Fork-Lift Operator Music Leading Solar/Wind Energy
Child Care Gardening Music Performing Teaching
Christian Education HTML/Web Design Office Work Typing
Civil Engineering Irrigation Pastor Video/Photography
Computers Landscaping Professor Water Systems Engineering
Cooking Legal Help Puppetry/Clowning Writing
Counseling Leading Bible Study Quilting Other
Crafts Leading VBS Recreation Other

Construction Skills

Skills Prof Inter Novice Skills Prof Inter Novice
Blueprinting Masonry
Carpentry Painting
Code Specialist Paving
Concrete Plastering
Coordinating Plumbing
Drywall Roofing
Electrical Surveying
General Contractor Welding
Glass/Glazing Well Drilling
Heating/Air Woodworking
Insulation

Health Care           
                    Status:    Student    Active    Retired

Allergist Hospital Administrator Oral Surgeon
Anesthesiologist Internist Orthopedist
Bio-Med Tech Lab Technologist Pediatrician
Cardiologist Mental Health Provider Pharmacist
Chiropractor Nurse Physical Therapist
Counselor Nurse Anesthetist Podiatrist
Dental Hygt./Asst Nurse Midwife Radiologist
Dentist Nurse Practitioner Speech/Hearing
Dermatologist OB/GYN Surgeon
EMT/Paramedic Ophthalmologist Veterinarian
Family Practitioner Optometrist X-Ray Tech
Other
Signature:___________________ Date:____/____/____   (m/d/y)

Please print, fill out and mail
your completed Volunteer Data Form to (at the moment you cannot submit it online):
Mission Volunteers Office - GBGM
475 Riverside Drive, Suite 330
New York, NY 10115

Thank you for your time and effort!!

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