Volunteer


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'); }elseif($CaptchaImage == "1") { include_once $pathtoIncludes . 'securimage.php'; $securimage = new Securimage(); if ($securimage->check($_POST['captcha_code']) == false) { die('The letters you entered for the security image did not match the letters on the image. Please go back and correct it.'); } }if(((($liame) && strstr($liame,"@") && strstr($liame,"."))||($RequireEmail=='0')) && ($totaltime>='2')&&(($RequireSession != 1)||(!isset($_SESSION['check']))||($_SESSION['check'] >= 1))){ if($InsertDB == 1) { $newid = insert($table_main,$date,$Title,$FirstName,$LastName,$Age,$School,$LastGrade,$Address,$City,$State,$Zip,$Telephone,$BusPhone,$Cell,$Carrier,$Text_message,$Beeper,$Ref_Name_1,$Ref_Phone_1,$Ref_Relat_1,$Ref_Name_2,$Ref_Phone_2,$Ref_Relat_2,$Emerg_Last_Name,$Emerg_First_Name,$Emerg_Home_Phone,$Emerg_Bus_Phone,$Emerg_Relat,$Employer,$Job_Title_1,$Emp_Address,$Emp_City,$Emp_State,$Emp_Zip,$Emp_Month,$Emp_Year,$Past_Employer,$Past_Job_Title_1,$Past_Emp_Address,$Past_Emp_City,$Past_Emp_State,$Past_Emp_Zip,$Past_Emp_Month_Start,$Past_Emp_Year_Start,$Past_Emp_Month_End,$Past_Emp_Year_End,$Vol_Org_1,$Vol_Job_Title_1,$Vol_Address_1,$Vol_City_1,$Vol_State_1,$Vol_Zip_1,$Vol_Month_1_Start,$Vol_Year_1_Start,$Vol_Month_1_End,$Vol_Year_1_End,$Vol_Org_2,$Vol_Job_Title_2,$Vol_Emp_Address_2,$Vol_Emp_City_2,$Vol_Emp_State_2,$Vol_Emp_Zip_2,$Vol_Emp_Month_2_Start,$Vol_Emp_Year_2_Start,$Vol_Emp_Month_2_End,$Vol_Emp_Year_2_End,$HoursAvail,$Languages,$Skills,$Car,$Drive,$Lic_Num,$Times,$Tutoring,$Email,$Hos_Respite_Day,$Home_Respite_Day,$Hos_Respite_Evening,$Hos_Respite_Night,$Translation,$Arrange_Events,$Volunteer_for_Chai_Lifeline,$Big_Brother,$Office,$Other,$Comment,$Arrested,$dob,$social,$Emp_Years,$employed,$SchoolName,$Degree,$VolMonday,$VolWed,$VolMonAndWed,$HearAbout,$VolSignature,$region,$httpReferer,$ip,$http_agent); } sendEMail($emailto,$emailfrom,$sitename,$subject,$CustomerEmail,$CustomerSubject,$CustomerMessage,$newid,$date,$Title,$FirstName,$LastName,$Age,$School,$LastGrade,$Address,$City,$State,$Zip,$Telephone,$BusPhone,$Cell,$Carrier,$Text_message,$Beeper,$Ref_Name_1,$Ref_Phone_1,$Ref_Relat_1,$Ref_Name_2,$Ref_Phone_2,$Ref_Relat_2,$Emerg_Last_Name,$Emerg_First_Name,$Emerg_Home_Phone,$Emerg_Bus_Phone,$Emerg_Relat,$Employer,$Job_Title_1,$Emp_Address,$Emp_City,$Emp_State,$Emp_Zip,$Emp_Month,$Emp_Year,$Past_Employer,$Past_Job_Title_1,$Past_Emp_Address,$Past_Emp_City,$Past_Emp_State,$Past_Emp_Zip,$Past_Emp_Month_Start,$Past_Emp_Year_Start,$Past_Emp_Month_End,$Past_Emp_Year_End,$Vol_Org_1,$Vol_Job_Title_1,$Vol_Address_1,$Vol_City_1,$Vol_State_1,$Vol_Zip_1,$Vol_Month_1_Start,$Vol_Year_1_Start,$Vol_Month_1_End,$Vol_Year_1_End,$Vol_Org_2,$Vol_Job_Title_2,$Vol_Emp_Address_2,$Vol_Emp_City_2,$Vol_Emp_State_2,$Vol_Emp_Zip_2,$Vol_Emp_Month_2_Start,$Vol_Emp_Year_2_Start,$Vol_Emp_Month_2_End,$Vol_Emp_Year_2_End,$HoursAvail,$Languages,$Skills,$Car,$Drive,$Lic_Num,$Times,$Tutoring,$Email,$Arrange_Events,$Volunteer_for_Chai_Lifeline,$Big_Brother,$Hos_Respite_Day,$Home_Respite_Day,$Hos_Respite_Evening,$Hos_Respite_Night,$Translation,$Office,$Other,$Comment,$Arrested,$dob,$social,$region,$regionEmail,$Emp_Years,$employed,$SchoolName,$Degree,$VolMonday,$VolWed,$VolMonAndWed,$HearAbout,$VolSignature,$httpReferer,$ip,$http_agent,$totaltime); message('
 
Thank you for contacting us.

We received your volunteer information and a representative will get back to you shortly.'); $_SESSION['check'] = 0; }else{ echo '

There was an error submitting this form. Please contact our office. (Error code: TT-'.$totaltime.'-'.$_SESSION['check'].')

'; } break; default : showFrm($CaptchaImage,$pathtoIncludes); } function showFrm($CaptchaImage,$pathtoIncludes) { ?>
Personal Information
Employment Information
Are you currently employed? yes no
Student Information
Are you currently a student? yes no
References
Reference #1
Reference #2
Emergency Information
Volunteer Experience
Experience #1
Experience #2
Volunteer Information
I-shine Operates Monday & Wednesday 3:45-6:30PM

Please select the days you are available to volunteer
Monday Wednesday Both Monday & Wednesday
Agreement Information
Have you ever been convicted of any crime, including sex-related or child abuse related offenses in any state or country?
yes no
I have truthfully completed this application. I will honor the time commitment required for my volunteer assignment and will adhere to all policies and procedures outlined in any materials provided by Chai Lifeline.

Agreement of Confidentiality
As an i-Shine volunteer, I understand that in the course of my work with this program, I might learn privileged and confidential information about the children and their families, including, but not limited to medical conditions and treatment, finances, living arrangements, employment, and/or relationships among family members. I understand that all such information must be treated as confidential. I agree to disclose any information learned about patients and their family members only to one of the adult coordinators of the program. I understand unauthorized disclosures are considered grounds for immediate termination of volunteer status.
Security Image
Please enter the letters or digits that appear in the security image below
CAPTCHA Image 

'); if($CustomerEmail == 1) { mail($Email, $CustomerSubject, $CustomerMessage, 'From: "'.$sitename.'" <'.$emailfrom.'>'); } if(!$SentSuccess) { die('

There was an error emailing this form. Please contact our office.

'); } return; } function message($message) { echo "

$message

"; // Don't allow to refresh page // $curLocation = $_SERVER['PHP_SELF'].'?action= '; // header( "Location: $curLocation" ); } ?>