Deafblind Shabbaton 2019: SSP/Volunteer Application

1. Name 1. Name First Last
2. Address 2. Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3. Cell Phone Number 3. Cell Phone Number - ### - ### ####
3a. The above phone number is:

3a. The above phone number is: Voice TTY VP Text
4. Email
5. Gender:
6. How did you learn about the Shabbaton?

7. Please describe your experience level for the following:
	None	Minimal	Some	Significant
Guiding people who are Deafblind	Guiding people who are DeafblindNone	Guiding people who are DeafblindMinimal	Guiding people who are DeafblindSome	Guiding people who are DeafblindSignificant
Describing visual information to people who are Deafblind	Describing visual information to people who are DeafblindNone	Describing visual information to people who are DeafblindMinimal	Describing visual information to people who are DeafblindSome	Describing visual information to people who are DeafblindSignificant
Interpreting between spoken English and American Sign Language	Interpreting between spoken English and American Sign LanguageNone	Interpreting between spoken English and American Sign LanguageMinimal	Interpreting between spoken English and American Sign LanguageSome	Interpreting between spoken English and American Sign LanguageSignificant
Interpreting between spoken English and Signed English	Interpreting between spoken English and Signed EnglishNone	Interpreting between spoken English and Signed EnglishMinimal	Interpreting between spoken English and Signed EnglishSome	Interpreting between spoken English and Signed EnglishSignificant

8. Please describe your skill level in:
8. Please describe your skill level in:	Beginner	Advanced Beginner	Intermediate	Advanced
American Sign Language	American Sign LanguageBeginner	American Sign LanguageAdvanced Beginner	American Sign LanguageIntermediate	American Sign LanguageAdvanced
Signed English	Signed EnglishBeginner	Signed EnglishAdvanced Beginner	Signed EnglishIntermediate	Signed EnglishAdvanced

8a. Please describe your interpreting experience:

8b. Please indicate the interpreting situations in which you are comfortable:
	Beginner	Advanced Beginner	Intermediate	Advanced
Platform Interpreting	Platform InterpretingBeginner	Platform InterpretingAdvanced Beginner	Platform InterpretingIntermediate	Platform InterpretingAdvanced
One:One Interpreting	One:One InterpretingBeginner	One:One InterpretingAdvanced Beginner	One:One InterpretingIntermediate	One:One InterpretingAdvanced
Small Group Interpreting	Small Group InterpretingBeginner	Small Group InterpretingAdvanced Beginner	Small Group InterpretingIntermediate	Small Group InterpretingAdvanced

9. If you are a student, please list your highest level ASL course, linguistics courses and/or Deaf culture classes.

10. Please check any language, code, and/or modality within which you are comfortable interpreting. Please indicate your preference by numbering.
	Not Comfortable	Slightly Comfortable	Comfortable	Somewhat Comfortable	Very Comfortable
ASL	ASLNot Comfortable	ASLSlightly Comfortable	ASLComfortable	ASLSomewhat Comfortable	ASLVery Comfortable
PSE	PSENot Comfortable	PSESlightly Comfortable	PSEComfortable	PSESomewhat Comfortable	PSEVery Comfortable
Signed English	Signed EnglishNot Comfortable	Signed EnglishSlightly Comfortable	Signed EnglishComfortable	Signed EnglishSomewhat Comfortable	Signed EnglishVery Comfortable
Tactile Sign	Tactile SignNot Comfortable	Tactile SignSlightly Comfortable	Tactile SignComfortable	Tactile SignSomewhat Comfortable	Tactile SignVery Comfortable
Close Vision	Close VisionNot Comfortable	Close VisionSlightly Comfortable	Close VisionComfortable	Close VisionSomewhat Comfortable	Close VisionVery Comfortable
Restricted Space	Restricted SpaceNot Comfortable	Restricted SpaceSlightly Comfortable	Restricted SpaceComfortable	Restricted SpaceSomewhat Comfortable	Restricted SpaceVery Comfortable

11. Please indicate your dominant signing hand:

11. Please indicate your dominant signing hand: Left Right

12. Please indicate your level of Jewish knowledge in the following ways:
	None	Minimal	Some	Advanced
I am familiar with Jewish culture	I am familiar with Jewish cultureNone	I am familiar with Jewish cultureMinimal	I am familiar with Jewish cultureSome	I am familiar with Jewish cultureAdvanced
I am familiar with Jewish religious practices	I am familiar with Jewish religious practicesNone	I am familiar with Jewish religious practicesMinimal	I am familiar with Jewish religious practicesSome	I am familiar with Jewish religious practicesAdvanced
I am able to read/speak Hebrew	I am able to read/speak HebrewNone	I am able to read/speak HebrewMinimal	I am able to read/speak HebrewSome	I am able to read/speak HebrewAdvanced
I am able to interpret between English, Hebrew, and American Sign Language	I am able to interpret between English, Hebrew, and American Sign LanguageNone	I am able to interpret between English, Hebrew, and American Sign LanguageMinimal	I am able to interpret between English, Hebrew, and American Sign LanguageSome	I am able to interpret between English, Hebrew, and American Sign LanguageAdvanced

13. I prefer to only touch people of the same gender

13. I prefer to only touch people of the same gender Yes No
14. Would you be willing to help with transportation needs on Friday and/or Sunday?

14. Would you be willing to help with transportation needs on Friday and/or Sunday? Yes No
15. Are there other (non-interpreting) areas of interest or special skills that might benefit the participants and the weekend, such as physical activity or sport (adaptable); art; Kosher cooking. If yes, please describe:
16. When will you be at the weekend? Please be specific! If not full-time, we must know which overnights and which meals because we pay for your bed and your meals.

16. When will you be at the weekend? Please be specific! If not full-time, we must know which overnights and which meals because we pay for your bed and your meals. Full time (arrive by 10am Friday and leave at noon on Sunday) Part time (Specify the day(s) and time below)

17. Please indicate the times you plan to participate. Please note there is no breakfast choice for Friday and no lunch or dinner choice for Sunday.
	Friday	Saturday	Sunday	Not Applicable
7 – 10 am (includes breakfast)	7 – 10 am (includes breakfast)Friday	7 – 10 am (includes breakfast)Saturday	7 – 10 am (includes breakfast)Sunday	7 – 10 am (includes breakfast)Not Applicable
10 am – 1 pm (includes lunch)	10 am – 1 pm (includes lunch)Friday	10 am – 1 pm (includes lunch)Saturday	10 am – 1 pm (includes lunch)Sunday	10 am – 1 pm (includes lunch)Not Applicable
1 pm – 6 pm	1 pm – 6 pmFriday	1 pm – 6 pmSaturday	1 pm – 6 pmSunday	1 pm – 6 pmNot Applicable
6 pm – 11 pm (includes dinner)	6 pm – 11 pm (includes dinner)Friday	6 pm – 11 pm (includes dinner)Saturday	6 pm – 11 pm (includes dinner)Sunday	6 pm – 11 pm (includes dinner)Not Applicable
Need overnight accommodations	Need overnight accommodationsFriday	Need overnight accommodationsSaturday	Need overnight accommodationsSunday	Need overnight accommodationsNot Applicable

18. Please fully describe any food restrictions or allergies, including food preferences, such as no red meat or fish, so that we can best accommodate your needs. All food will be strictly Kosher.
19. Please check one: I tend to be:

19. Please check one: I tend to be: Early-Bird Night-Owl
In case of an emergency contact:
Name: Name: First Last
Primary Phone: Primary Phone: - ### - ### ####
This telephone number is:

This telephone number is: Voice Text TTY VP
Please indicate any serious health condition you feel we should be aware of (diabetes, heart problems, allergies, epilepsy):
Please make sure any medication you must bring with you is clearly labeled according to law.
Medical Release:
In the event of a medical emergency where my consent cannot be readily obtained, the staff are authorized to consent on my behalf for necessary medical treatment., including, but not limited to medication, anesthesia or surgery.
I agree to not hold liable the event coordinators if injured during the weekend.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Permissions:

I give permission to photograph and videotape me during the weekend, which may be used for future publicity. (No photos or video will be taken on Shabbat.)

I give permission for my contact information to be saved by the CJE for communication relating to future Deafblind Shabbatons.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Deafblind Shabbaton 2019: SSP/Volunteer Application

Deafblind Shabbaton 2019: SSP/Volunteer Application

In case of an emergency contact:

Please make sure any medication you must bring with you is clearly labeled according to law.

Permissions: I give permission to photograph and videotape me during the weekend, which may be used for future publicity. (No photos or video will be taken on Shabbat.) I give permission for my contact information to be saved by the CJE for communication relating to future Deafblind Shabbatons.

Permissions:

I give permission to photograph and videotape me during the weekend, which may be used for future publicity. (No photos or video will be taken on Shabbat.)

I give permission for my contact information to be saved by the CJE for communication relating to future Deafblind Shabbatons.