Roanoke Outreach (VIR-102-10)

Mission Volunteer Form Please complete the following form to offer your individual, family, or team support! (Please use Internet Explorer.* Denotes required fields.)

Personal Data Please provide the following for your group organizer: Prefix * First Name Middle Name * Last Name Suffix Date of Birth Format = MM/DD/YYYY * Gender Male Female

Contact Information Please tell us how to get in touch with you: * Email Format = email@domain.ext Home Phone Format = ###-###-#### Mobile Phone Format = ###-###-####

Organization Details Please provide details about your group: Church/Organization Address 1 Street Address, PO Box Address 2 Apartment, Suite, Unit, Building, Floor, and Etc. City State/Province/Region ZIP/Postal Code Country United States Andorra Andorra United Arab Emirates Afghanistan Antigua And Barbuda Anguilla Albania Armenia Netherlands Ant Illes Angola Antarctica Argentina American Samoa Austria Australia Aruba Azerbaijan Bosnia And Herzegowina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Bermuda Brunei Darussalam Bolivia Brazil Bahamas Bhutan Bouvet Island Botswana Belarus Belize Canada Cocos (Keeling) Islands Central African Republic Congo Switzerland Cote D'Ivoire Cook Islands Chile Cameroon China Colombia Costa Rica Cuba Cape Verde Christmas Island Cyprus Czech Republic Germany Djibouti Denmark Dominica Dominican Republic Algeria Ecuador Estonia Egypt Western Sahara Eritrea Spain Ethiopia Finland Fiji Falkland Islands (Malvinas) Micronesia, Federated States Faroe Islands France Gabon United Kingdom Grenada Georgia French Guiana Ghana Gibraltar Greenland Gambia Guinea Guadeloupe Equatorial Guinea Greece South Georgia , S Sandwich Is. Guatemala Guam Guinea-Bissau Guyana Hong Kong Heard And Mc Donald Islands Honduras Croatia (Local Name: Hrvatska) Haiti Hungary Indonesia Ireland Israel India British Indian Ocean Territory Iraq Iran (Islamic Republic Of) Icel And Italy Jamaica Jordan Japan Kenya Kyrgyzstan Cambodia Kiribati Comoros Saint K Itts And Nevis Korea, Dem People'S Republic Korea, Republic Of Kuwait Cayman Islands Kazakhstan Lao People'S Dem Republic Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libyan Arab Jamahiriya Morocco Monaco Moldova, Republic Of Madagascar Marshall Islands Macedonia Mali Myanmar Mongolia Macau Northern Mariana Islands Martinique Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia Niger Norfolk Island Nigeria Nicaragua Netherlands Norway Nepal Nauru Niue New Zealand Oman Panama Peru French Polynesia Papua New Guinea Philippines Pakistan Poland St. Pierre And Miquelon Pitcairn Puerto Rico Portugal Palau Paraguay Qatar Reunion Romania Serbia Russian Federation Rwanda Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore St. Helena Slovenia Svalbard, Jan Mayen Islands Slovakia (Slovak Republic) Sierra Leone San Marino Senegal Somalia Suriname Sao Tome And Principe El Salvador Syrian Arab Republic Sw Aziland Turks And Caicos Islands Chad French Southern Territories Togo Thailand Tajikistan Tokelau Turkmenistan Tunisia Tonga East Timor Turkey Trinidad And Tobago Tuvalu Taiwan Tanzania, United Republic Of Ukraine Uganda United States Minor Is. United States Uruguay Uzbekistan Holy See (Vatican City State) Saint Vincent, The Grenadines Venezuela Virgin Islands (British) Virgin Islands (U.S.) Viet Nam Vanuatu Wallis And Futuna Islands Samoa Yemen Mayotte Yugoslavia South Africa Zambia Zaire Zimbabwe

Team Information Please provide details regarding your team and its availability: Start Date MM/DD/YYYY End Date MM/DD/YYYY Team Individual Total Team Members Members Over 21 yrs. Personal Skills (e.g. Construction, Painting, VBS, Music, Worship, etc.)

Other Comments or Requests

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Please contact Craig Waddell or Nichole Prillaman
with any related questions, suggestions, or requests.