190 Oakland Street ·
Gastonia, North Carolina 28052
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Last Name: ______________________ First Name: ____________________ Middle: ____________ Home Address: _____________________________ City:____________ State: ____ Zip: _________ Business Address: __________________________ City: ___________ State: _____ Zip: ________ Home Phone: _______________________________ Work Phone: ___________________________ Mobile Phone: _______________________________ E-mail: _______________________________ Area of Service: ____________________________________________________________________ Language Skills Other Than English: ___________________________________________________ Emergency Contact: ________________________________________________________________
Statistical Information This unit of the American Red Cross, in recognition of its responsibility to its paid and volunteer staff and this community it serves, reaffirms its policy to assure fair and equal treatment in all of its employment practices, for all persons. We will not discriminate on the basis of race, color, religion, sex, age, or national origin nor against any qualified handicapped individual, disabled veteran or veteran of the Vietnam Era. The following information is requested solely to determine the diversity of the Red Cross Volunteers. Completion is optional; however, it would be most helpful to us as we monitor the complete record of our program. (Please
circle) Disabled: Yes No If yes, please explain: _______________________________________ Ethnic
Group: Black Hispanic
Asian/Pacific Islander
White American Indian/Alaskan Date of Birth: ______________________ Age: ________ Years of Service: ____________________ Employed Unemployed Retired Student Homemaker
©
2002 American Red Cross, Gaston County Chapter |