Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Phone *

Which is the best number to reach you at?

Country

(###)

###

####

How did you hear about us?

Online Search

Heard from a Friend

PostCard, Poster, Brochure

Other

Which is the best way to contact you? *

Please choose all that apply.

Email

Phone

Texting is great

Address

(If you don't have a current address, please use the address of the shelter or home that you mostly stay in. If you don't know, you may leave this blank.)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Income Source

Optional

Self Sufficient

Government Funding

Family

None

Other

Please acknowledge the following: The Keramiko mentor/volunteer(s) that you may be paired with, are to be respected and treated with dignity. They will treat you in the same manner. Keramiko workers are never to be put in harms way. Your mentor should not be taken for granted or looked on as someone who is there to just provide items or services for you, but rather is a gift of friendly support. *

I understand

I disagree