Home 5 Intake Forms 5 General Intake Form General Intake Form 1General Information2Publicity Release3Health Insurance4Student Loan Information5 Name (exactly as it appears on your ID)*We will use this to book flights/travel for you, so it's important this name matches your ID. If you have a different preferred name, let us know that below. First Last Date of Birth* MM slash DD slash YYYY Preferred NameChosen name or nicknamePronounsi.e. she/her/hers, zi/zir/zirs, he/him/his, they/them/theirs, etc.IdentitiesIt’s important to QVS staff to have an understanding of the identities you hold in order to shape our programming and affinity groups throughout the year. Please check all that apply. African Descent (Black) Asian Descent Hispanic / Latinx Middle Eastern Descent Multi-Racial Native American / Alaskan Native Pacific Islander White / European Descent International Owning Class Working Class Mixed/Middle Class Working Poor Queer Straight Questioning (sexuality) Trans Cis Non-binary Female Male Questioning (gender) Other We recognize the limitations of a demographic survey and provide this optional space for you to elaborate and/or describe your identities in your own words.Primary Email Address*All QVS-related correspondence will be sent here. Please do not use your college email address if it will expire. Mobile Phone Number*City you will serve in* Boston, MA Minneapolis/St.Paul, MN Philadelphia, PA Portland, OR What site placement organization will you be working with?*What is your alma mater (if applicable)?Enter your college/university, if applicableWith what religious practice(s)/tradition(s) do you identify? (if any)Travel to QVS National Orientation*We recognize that the cost of travel may be a barrier for many Fellows coming from lower economic class backgrounds and / or wealth privilege. Our organization is continuously growing in our class consciousness and is offering to cover up to $350 of Fellows’ travel costs to QVS orientation at Pendle Hill (outside of Philadelphia). Additionally, we have an opt-out option for those with the financial means to get to orientation. Please select between the options below. I need support from QVS in getting to orientation. I opt-out because I have the means to get myself to orientation and would rather this money go back into QVS’s equity funds, which allows QVS to provide support in other areas where it is needed. QVS staff will follow up with you about your travel needs later this summer. What is your city of origin for travel to orientation?*Dietary Requirements / Food Preferences* Gluten Free Omnivore Pescatarian Vegan Vegetarian Please describe any food allergies or restrictions you have.T-Shirt Size*Unisex XSUnisex SUnisex MUnisex LUnisex XLUnisex XXLUnisex XXXLOtherOther:Are you planning to bring a car with you to QVS?*We generally discourage Fellows from bringing a vehicle with them for their service year due to cost of insurance, equity in transportation in the house, parking availability, unexpected maintenance costs, etc. Some placements do require or encourage Fellows to have a car, or some Fellows have responsibility for a vehicle they will need to continue through the year, and we are glad to work with you if that is the case. QVS folks will follow up with you if you are planning to bring a car. Yes No Maybe / Unsure Publicity ReleaseAll QVS Fellows are asked to sign a publicity release giving QVS permission to use your appearance and name in QVS publications, press releases, on our website, Facebook, Instagram feed, Twitter, or in other materials related to the QVS program:As a member of the Quaker Voluntary Service (QVS) program, I irrevocably grant and convey to QVS, without limitations, all right, title, and interest in any and all images taken of me during my activities with QVS including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. I give my permission to QVS to use my image in photographs and my name in any QVS publications, press releases, website, Facebook page, or other materials related to the QVS program. I also understand that under no circumstances am I to receive any additional monies or ask for any additional monies if my image or name is used.* I consent to the terms put forth in this publicity agreement. I do NOT give my permission. Health InsuranceIt is important that you have health insurance during your year with QVS. If you are 26 years or younger, you are able to remain on a parent’s insurance plan. If for any reason you are unable to remain on your parent's insurance, QVS will facilitate access to basic coverage. Will you remain on a parent's insurance plan (or other plan) throughout this service year?* Yes No What is your insurance plan name?*e.g., Blue Shield PPO, Aetna HMO, etc.QVS Insurance EnrollmentQVS contracts through Catholic Volunteer Network (CVN) to obtain basic health insurance for individuals who are not enrolled through a parent's plan or who are unable to obtain affordable coverage on the insurance exchange. Please fill out the form below so that we may enroll you in CVN coverage. Name* First Last Sex*This is information that our provider requires, though QVS as a program acknowledges that there are genders and sex identities beyond this binary. Female Male Date of Birth* MM slash DD slash YYYY Social Security Number9 digits, no dashesSignature*Use your mouse or finger to draw your signature above Student Loan InformationQVS offers a student loan help program in which interested Fellows can receive help deferring or consolidating student loans. In instances of demonstrated need, QVS may also contribute toward loan payments for loans which cannot be deferred.Are you interested in QVS's help with your student loans?* Yes No QVS staff will reach out about this support soon. Contact staff at [email protected] if you need to connect about this immediately. COVID-19 VaccinationBecause Fellows work directly with some of the most vulnerable communities, and those communities are disproportionately impacted by Covid, we require that all 2023-2024 Fellows be fully vaccinated and receive appropriate boosters against Covid. Please upload a photo of your Covid vaccination & booster card (jpg, gif, pdf).*Accepted file types: jpg, gif, pdf, Max. file size: 50 MB. Δ
