Contact Details

First Name

Last Name

Address Line 1

City

State

Postal Code

Email

Date of Birth (MM/DD/YYYY)

Veteran?

YesNo

Gender

MaleFemaleOther

Areas of Interest

CPV HQSouthern Tier

Home Phone

Mobile Phone

Are you a practitioner interested in volunteering in our wellness program?

YesNo

Modality

AcupunctureMarmaMassage or ReflexologyMeditationPolarityReiki or Quantum Touch YogaQigongOther

Date of License/Certification

Date of License Expiration

License Certification by

Date of License / Certification 2

Date of License Expiration 2

License Certification by 2

If your license / certification requires insurance, please indicate effective date

I can commit to

1 Day Per Month2 Days Per Month3 or More Days Per MonthOther

Days of the Week I Prefer to Volunteer

SundayMondayTuesdayWednesdayThursdayFridaySaturday

Please list three references with contact information
Reference #1

Reference #2

Reference #3

What is your experience with military, or warrior culture?

Comments

Are you applying for an Internship at Clearpath?

YesNo

School/Program Advisor Information

School Name

Advisor First Name

Advisor Last Name

Advisor Phone

Advisor Email

Are you volunteering with a group?

YesNo

Organization or Group:

How did you hear about Clear Path?

Please share any special skills, interests and anything else you would like to tell us about yourself.

Please share any special skills, interests and anything else you would like to tell us about yourself.

Emergency Contact Information

First Name

Relationship

Phone

Last Name

Click below to acknowledge that you accept the terms and conditions of the Clear Path for Veterans Volunteer Waiver. To see the full text of the volunteer waiver, click here

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Contact Information