Small Steps for Big Changes Coach | Volunteer Application Volunteer InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth*MM/DD/YYYYEmergency Contact InformationEmergency Contact* First Last Emergency Contact Phone*Relationship to Applicant*References (Please list three)1. Reference Name First Last 1. Relationship to Applicant1. Reference Phone1. Reference Email 2. Reference Name First Last 2. Relationship to Applicant2. Reference Phone2. Reference Email 3. Reference Name First Last 3. Relationship to Applicant3. Reference Phone3. Reference Email Availability / ExperienceMust be available a minimum of two days / weekPlease list the dates and times you are available to volunteerPlease list any relevant volunteer or work experiencePlease list any relevant training or educationAs a YMCA VolunteerConsent* I am committed to supporting the YMCA of Regina’s mission, vision and values.*Consent* I am required to provide the YMCA of Regina with a current criminal record check prior to starting*Consent* I am required to participate in volunteer training prior to starting.*Release of Liability and Assumption of Risk WaiverRelease of Liability and Assumption of Risk Waiver* I understand that the YMCA of Regina assumes no responsibility for injuries or illnesses which I, my spouse/partner, or my minor children or any other person may sustain as a result of my/their physical condition, this program, my/their use of any facility or my/their participation in any activities, programs, exercise, or use of any equipment (collectively, “Activities”). I expressly acknowledge on behalf of myself, my spouse/partner, my minor children and our heirs that I assume the risk for any and all injuries, illnesses, death, loss or damage which may result from any of the foregoing. I herby release and discharge the YMCA of Regina, its agents, servants, and employees from any and all claims for injury, illness, death, loss or damage which I, my spouse/partner, or minor children may suffer as a result of their physical condition, this program, the use of any facility, or participation in any Activities. Participants are prohibited from possessing or using alcohol, tobacco products, non-prescription drugs, and weapons of any kind. Participants must follow safety instructions of YMCA staff, and refrain from harmful behavior. Failure to comply with thes YMCA policies will result in immediate dismissal from YMCA programs without refund.*Consent* By checking this box and typing my name below, I certify that this information is true and correct to the best of my knowledge.Name for form consent*(First and last)
