Please complete this application form if you are interested in becoming a Phillips Eye Institute - Early Youth Eyecare volunteer. Once you complete the form, click the submit button at the bottom. Please Note we do require training to be come a Lead Vision Screener. More information to follow.

Name and address

First name:

Last name:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Home phone:

Email address:

Emergency Contacts

First name:

Last name:

Cell phone:

Relationship:

Relevant Volunteer and/or Employment experience

Please list any experience relevant to volunteering for E.Y.E. program.

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

(year optional)

Gender:

Major degree:

School:

Organization:

Be sure to accept all emails as that is our main form of communication regarding cancellations, time changes etc. Check your spam folder if you run in to any issues.

Background Check

We will have you complete a back ground check during your training orientation.

Languages Spoken?

Please list any other languages you speak.

How did you hear about us?

Posting on Volunteer Board, Friend, Co-worker, School, etc

Agreement

I understand that submitting this information does not guarantee my acceptance as a volunteer for the E.Y.E. Program. Assignment of volunteer work is based on the assessment made by E.Y.E. Staff.

I understand that continued participation in the E.Y.E. Program is at the discretion of E.Y.E. Staff.

I understand that by completing the attached Request for Background Study form, I give the E.Y.E. Program & Phillips Eye Institute permission to perform all necessary background checks to serve as an E.Y.E. Program volunteer.

I Agree