Name: Email Address: Phone Number Alternate Phone Number What are your talents/special interests? (check all that apply) Cooking Crafts Building projects Electrical work House painting Singing Organizing Fundraising Ideas Other If you chose "other", please list these talents/special interests here What areas would you like to be involved in with the Civitan Club? Please list your place of worship (if applicable) Do you have children? Yes No If yes, how many? 1 2 3 4 5 6 7 Please list their names and ages (1 per line please) What is your availability for working with the Civitan Club projects? Sunday AM Sunday PM Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Saturday AM Saturday PM

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