PLEASE PRINT CLEARLY. THIS INFORMATION WILL BE KEPT CONFIDENTIAL.

Name:

Daytime phone number: Discretion required Yes No

Evening phone number: Discretion required Yes No

E-mail address:              Discretion required Yes No

The answers to the next three questions are voluntary 
(SO YOU DO NOT HAVE TO ANSWER THEM).

Responses will help us select appropriate volunteers for age/gender/identity-specific 
Project activities.

My age :

under 19 19-29 30-39 40-49 50-59 60-69 70+

I am :(please check all that apply):

Female Female to Male Androgyne Third (4th, etc. Gendered) Male Male to Female Intersex  Non-Gendered  Transgendered (please specify):   Other (please specify):

My sexual orientation is:

Asexual Gay Male Heterosexual Lesbian Bisexual Gay Female Pansexual   Other (please specify):

I am interested in helping out with (please check all that apply):

Out-reach to multicultural communities Out-reach to youth Out-reach to workplaces Out-reach to rural communities Out-reach to seniors Out-reach to people with disabilities Out-reach to people who are incarcerated Web Site development Graphics Development of posters, brochures Distribution of posters, brochures

Organizing workshops Organizing focus groups Staffing information booths Phoning Faxing

 Liaison with service providers and GLBT community organizations
 Translation services.  If so:  English to French and/or to
 Other (please specify)

I have the following skills/experience: 

In addition to English I speak:  French  Other (please specify)

I am connected to the following communities/organizations: 

I am generally available:

Weekdays (9:00 a.m. - 5:00 p.m.) Weekend days (9:00 a.m. - 5:00 p.m.)

Weekday evenings (5:00 p.m. - 11:00 p.m.) Weekend evenings (5:00 p.m. - 1:00 p.m.)

  Other (please specify)