Distribution Volunteer Application

Thank you for your interest in being a volunteer for one of our overseas wheelchair distributions. Since we have limited space on these trips we do have to decline some applicants. Please fill out the form to the best of your knowledge and we will be in contact with you. If you have any questions about the application please send an email to info@rocwheels.org.

Name *
Name
Address *
Address
Home Address
Phone *
Phone
What is the best way to contact you? *
Check all that apply.
Date of Birth *
Date of Birth
This information is solely for the ROC Wheels Inc. staff
If yes, list restrictions
Medical Information
Emergency Contact Information
Name of Contact *
Name of Contact
Phone Number of Emergency Contact *
Phone Number of Emergency Contact
Reference
Please give the name of someone (non-relative) you know for a personal reference: *
Please give the name of someone (non-relative) you know for a personal reference:
Phone Number of Reference *
Phone Number of Reference
Address of Reference
Address of Reference
Biography