Volunteer ApplicationName 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Date of Birth MM slash DD slash YYYY HiddenSocial 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 NoDo 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 PhoneΔ
