Participant Interest Form

Participant Section

First Name (*)

Please let us know your name.

Last Name (*)

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Date of Birth(*)

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Address(*)

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City, State Zip(*)

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Your Email(*)

Please let us know your email address.

Confirm Email(*)

Please confirm your email address.

County(*)

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Phone Number(*)

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Tell us about the potential GIFT participant (*)

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Why are you interested in participating GIFT? (*)

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High School Graduate?(*)

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Place of Employment (*)

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How many years of work experience? (*)

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Does the participant live with parents or caregiver?(*)

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If the participant does not live with a parent or caregiver, does he/she live completely independent or with support? Enter N/A if not applicable. (*)

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Does the participant have a driver license?(*)

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Does the participant drive independently?(*)

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Personal interests(*)

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Cognitive or medical diagnosis (*)

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Caregiver Section

First Name (*)

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Last Name (*)

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Relationship to participant (*)

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Address (*)

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City, State Zip (*)

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County (*)

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Email address (*)

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Phone number (*)

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How did you learn about GIFT? (*)

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Why are you interested in participating in GIFT? (*)

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Are you available to volunteer with GIFT? (*)

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When is the best time to contact you to discuss next steps? (*)

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Security Check(*)

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Submit