Volunteer Application Name 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 Email Date of Birth MM slash DD slash YYYY This field is hidden when viewing the formSocial Security NumberWork PhoneHome or Cell Phone I do not want to receive communications from Langton Green. Would you submit to a background check if necessary? Yes No Do you grant permission to be photographed for possible inclusion in a Langton Green Community Farm publication or other publications for promoting Langton Green Community Farm. Yes, I grant permission. No, I do not grant permission. I UNDERSTAND THE NATURE OF THE PROGRAM FOR WHICH I WISH TO VOLUNTEER AND CERTIFY THAT THE STATEMENTS ABOVE ARE TRUE AND CORRECT. I UNDERSTAND THAT THE FIRST 10 HOURS OF MY VOLUNTEER SERVICE WILL BE ON A TRIAL BASIS.SignatureDate MM slash DD slash YYYY Medical ReleaseIn the event that an emergency arises while volunteering at the Langton Green Community Farm requiring medical treatment, I authorize Langton Green, Inc. to select and designate nurses, physicians, and/or surgeons to furnish medical and/or surgical care, and I authorize such medical and/or surgical care, as in the judgment of a physician and/or surgeon holding a physician’s surgeon certificate issued by the Board of Medical Examiners of the State of Maryland, as may be needed and proper. I absolve the Langton Green Community Farm, nurses, physicians, and/or surgeons selected and designated by any of them, from any and all liability for their acts rendered in good faith.Volunteer SignatureDate MM slash DD slash YYYY Informed ConsentI recognize and understand that the activities of my volunteer project(s) at Langton Green, Inc. may be hazardous. I hereby expressly and specifically assume responsibility for any injury or harm resulting from these activities and release and discharge Langton Green, Inc. and representatives thereof from any and all liability for property damage, injury, illness, or death resulting from any volunteer activity.Volunteer SignatureDate MM slash DD slash YYYY Policies and ProceduresI have read and understand the policies and procedures of the Langton Green Community Farm.Volunteer SignatureDate MM slash DD slash YYYY Emergency ContactName First Last RelationshipEmergency Contact Phone Δ
