Sign Up to Volunteer with LightHouse for the Blind * These fields are required.Contact Information First Name * Nickname Last Name * Personal Pronoun (Ex: He, She, They, etc.) Email * Primary Phone * Phone Type * --None--HomeMobileFaxWorkTTY/VP Street * City * State --None--AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Zip * Country * United StatesAfghanistanAland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishWallis and FutunaWestern SaharaYemenZambiaZimbabwe How did you hear about LightHouse? * --None--Assisted Living FacilityCollege/University/SchoolCommunity Rehabilitation ProgramCommunity Senior ProgramConference/Meeting/EventD O REmail newsletterEmployer/Co-workerEye Care ProviderOther Medical ProviderFaith-Based OrganizationFamily Member/FriendIndependent Living CenterInternet SearchLightHouse EventLightHouse StaffLightHouse StudentLightHouse VolunteerLightHouse WebsiteOther Blindness OrganizationRegional CenterSelf-initiatedSocial MediaSocial Services AgencyTV/Radio/NewspaperTVI/O&M Specialist (K-12)VAOther Sources If you can recall more specifically, please elaborate. Company, Organization or School Affiliation Title Birthdate (mm/dd/yyyy) * Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Phone * Volunteering Information Do you have any physical, cognitive, or developmental limitations that may prevent you from safely performing certain tasks? If yes, please explain. * Have you ever been convicted of a felony? If yes, please explain the nature of the crime and the date of the conviction and disposition. * Would you be willing to provide professional and/or personal references upon request? * Groups, Clubs and Affiliations: Please list any groups or clubs you may be affiliated with while volunteering. Volunteer Certifications Describe any previous volunteer experience. * Describe any previous volunteer experience working with individuals who are blind or visually impaired. * Why do you wish to volunteer with the LightHouse? Volunteer Preferences Check below to indicate the type(s) of volunteer opportunities you are interested in. Personal Service Volunteer Fitness Partner LightHouse Agency Volunteer Event Volunteer Enchanted Hills Napa VolunteerNOTE: For the next few questions, please select all options that apply by using ctr/cmd+click. If you encounter any technical difficulties, please use the text box provided at the end of this section to type in your responses. What languages do you speak? Please select all applicable (ctr/cmd+click). We are fortunate to have students from all different backgrounds request volunteers. This will help in matching you with someone who prefers to speak in a language other than English or who speaks more than one language. ArabicASLCantoneseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHindiHmongHungarianItalianJapaneseKoreanMalay/IndonesianMandarinNorwegianNepaliPersianPolishPortuguesePunjabiRomanianRussianSomaliSpanishSudaneseSwedishTagalogThaiTurkishUkrainianVietnameseOther Skills/Interests: Please select (ctr/cmd+click) any and all skills of interest and experience. This will make for the most seamless volunteer project matching possible. * AccountingAdministrative / OfficeArtistic AbilityArts and craftsAssistive TechnologyBraille FluencyBraille TranscriptionCarpentryComputer UsageCookingCopy EditingDriver-TransportationGardeningGeneral HelpGraphic ArtsHandyman - GeneralHealth-WellnessLeadershipManual LaborMultimediaMusicPerforming ArtsPhotographyProgram FacilitationSports-FitnessVideographyVoice-OverWebsite Design / Development Schedule Preferences: Please select all (ctr/cmd+click) preferred days and times you would typically be available to volunteer. * Mon - MorningMon - AfternoonMon - EveningTue - MorningTue - AfternoonTue - EveningWed - MorningWed - AfternoonWed - EveningThu - MorningThu - AfternoonThu - EveningFri - MorningFri - AfternoonFri - EveningSat - MorningSat - AfternoonSat - EveningSun - MorningSun - AfternoonSun - Evening Distance Willing to Travel: Please select all areas you are willing to travel (ctr/cmd+click). This is especially important for those interested in becoming a Personal Services Volunteer (PSV) and/or Fitness Partner. * San FranciscoPeninsulaMarinEast BayNapa Do you have a valid California drivers license? * --None--YesNo On Call for Special Events and General Help: Would you like to be placed on our volunteer on-call list for special events and general help? * --None--YesNo Let's keep in touch! We LOVE keeping our wonderful volunteers in the loop with the news, opportunities and exciting developments at the LightHouse!So tell us, are you an eNews fan (via email) or a Quarterly Print Newsletter fan?Alternative formats are available! Please review the options below and choose (ctr/cmd+click) as many as you wish. Weekly E-mail NewsletterMonthly Youth eNewsletterQuarterly BrailleQuarterly Large PrintQuarterly Cassette Anything additional you would like us to know about you? Demographic Information This information is collected and used for Affirmative Action quarterly and yearly reporting purposes only. If you choose not to disclose some of this information, simply select 'Declined' from among the drop-down options. Thank you! Highest level of education completed * --None--No Formal SchoolingElementary (grades 1 - 8)Secondary, no high school diploma (grades 9 - 12)High School or Equivalency CertificatePost Secondary Education/Some CollegeBachelors DegreeMasters Degree or HigherDid Not Report Ethnicity * --None--AfricanAfrican AmericanAlaska NativeAsian OtherCambodianCaucasianChineseEastern EuropeanFilipinoJapaneseKoreanLaotianLatinoMiddle EasternNative AmericanPacific IslanderVietnameseMulti-EthnicOtherDeclined Gender * --None--MaleFemaleOtherDeclined Do you have a disability?* * --None--YesNoDeclined What is your level of vision?** * --None--Low Vision (not legally blind)Legally BlindTotally BlindNot Blind/Low VisionDeclined Are you over the age of 55? * --None--YesNoDeclined Are you a veteran?*** * --None--YesNoDeclined* Under the ADA Amendments Act of 2008, a disability is defined as: (1) a physical or mental impairment that substantially limits a major life activity; or (2) a record of a physical or mental impairment that substantially limited a major life activity; or (3) an actual or perceived impairment. ** Legal blindness is a level of vision loss that has been legally defined to determine eligibility for benefits. The clinical diagnosis refers to a central visual acuity of 20/200 or less in the better eye with the best possible correction, and/or a visual field of 20 degrees or less. *** A veteran is a person who served in the active military, naval, or air service, and who was discharged or released there from conditions other than dishonorable.