2023 Service Year Vietnam

Name *

First

Middle

Last

Cell phone number: *

Applicants e-mail address: *

Confirm Email

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Gender *

Male
Female
Other

Birthdate *

Age: *

T-shirt size: *

Men’s sizes

Applicant's Country of Citizenship: *

Passport Number: *

If you do not have one, put 0.

Passport Expiration Date

Beneficiary name: *

First

Last

For insurance purposes – usually spouse or parent.

Beneficiary's email address: *

Confirm Email

Beneficiary's phone *

Name of emergency contact: *

First

Last

Emergency contact's relationhsip to you: *

Emergency contact's e-mail address: *

Confirm Email

Emergency contact's phone number: *

Parent 1

Mother
Father
Guardian

Parent 1 name: *

First

Last

Parent 1 email: *

Confirm Email

Parent 1 cell phone: *

Parent 1 address:

Address Line 1

Address Line 2

City

State

Zip Code

If different than applicant’s.

Parent 1 place of employment: *

Parent 1 job title/position: *

Parent 2

Mother
Father
Guardian
Not Applicable

Parent 2 name: *

First

Last

Parent 2 email: *

Confirm Email

Parent 2 cell phone: *

Parent 2 address:

Address Line 1

Address Line 2

City

State

Zip Code

If different than applicant’s.

Parent 2 place of employment: *

Parent 2 job title/position: *

Name of high school or college/university currently enrolled: *

Enter second language(s) and your level of proficiency if applicable:

Do you volunteer currently? *

Yes
No
No, but I wish I was volunteering

If yes, how often do you volunteer? *

More than once per month
At least once per month
At least 2-4 times per month
Once per year or less
I do not currently volunteer

If you do not currently volunteer or do not do so often, please tell us why.

For example: not enough time, difficult to find service opportunities, etc.

If you do volunteer currently, please tell us why.

For example: class or club requirement, you enjoy helping others, etc.

In regards to the Summary of Understanding, Assumption of Risk, Waiver of Liability, Indemnification Agreement , Code of Conduct, and Polices for participation in the Youthlinc Service Year, I have carefully read these documents, fully understand and agree to the terms set forth in their content. I am aware that this is a release of liability and a contract between me and Youthlinc. I also acknowledge that this Agreement shall bind my heirs and personal representatives. *

I agree

Policies and Procedures

Signature of Participant *

Participant email for application confirmation *