Name *
Address *
Phone *
Emergency Contact *
Emergency Contact
Address 1 *
Address 1
Cell phone *
Cell phone
Checkbox *
By submitting this application, I certify that the facts set forth in this application are true to the best of my knowledge. I understand that falsification, misrepresentation, or concealment of information on this application may be sufficient grounds for disqualification from further consideration for volunteering or immediate discharge and NAMI Connecticut shall not be liable in any respect if my volunteer-ship is so denied or terminated. Furthermore, I realize that volunteer assignments are made on the needs of NAMI Connecticut in conjunction with my interests and skills. I further understand that my request to volunteer is made without expectation of any type of payment for services performed as a volunteer.