Volunteer Application Complete this form to apply to be an ACCESS RJ Volunteer First Name(Required)Last Name(Required)Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone(Required)Email(Required) Enter Email Confirm Email Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender Identity(Required) Female Male Nonbinary Not Listed Decline to Say If your gender identity was not listed, please provide it in the space below.(Required)Preferred Pronouns(Required) She/Her She/They They/Them He/Him He/They None, use my name Decline to Say Not Listed (Write In) If your pronouns were not listed, please provide them.(Required)Race/Ethnicity (Select All That Apply)(Required) African American/Black Asian Caucasian/White Chicanx Hispanic Latinx Middle Eastern Mixed Race/Multi-Ethnic Native American Pacific Islander South Asian Ethnicity Queer Decline to Say Not Listed If your race/ethnicity was not listed, please provide additional information.(Required)Languages You Speak (Select All That Apply)(Required) Arabic ASL Armenian Cantonese English French German Hmong Japanese Korean Mandarin Persian Portuguese Russian Spanish Tagalog Turkish Vietnamese Mien Not Listed Other If you speak any languages other than those listed, please provide additional information below.(Required)What types of support are you interested in providing?(Required) Comfort Kits Doula/Emotional Support Escort Funding Phonebanking Rallies Tabling Testifying Transportation What interests you most about ACCESS?(Required)0 of 1000 max charactersDo you have lived-experience with abortion? (Lived-experience can be categorized as you having had an abortion and/or you supporting someone that had an abortion)(Required) Yes, I have had an abortion. Yes, I have helped someone navigate an abortion. No, I do not have lived-experience. If you answered yes to the question above, did you or the person navigate abortion care before or after the Dobbs verdict in June 2022?(Required) I had an abortion/helped someone navigate an abortion BEFORE June 2022 I had an abortion/helped someone navigate an abortion AFTER June 2022 I had an abortion/helped someone navigate an abortion before AND after June 2022 Barriers exist to navigating abortion care even here in California. Please select which options best describe the barriers you or the person you helped experienced when navigating abortion care:(Required) Transportation Lodging Finances (unable to pay out-of-pocket procedural costs) Finances Other (unable to acquire time off, childcare, housing insecurity, unable to pay for groceries for family Provider limitations (distance from provider, unable to acquire timely appointment, unsatisfactory treatment) Gender Identity Stigma (personal, religious, media, misinformation) Risk of Criminalization Other If you answered "Yes, I have had an abortion", please select what best described your insurance situation when you received your abortion:(Required) I had private health insurance. I had Medi-Cal health insurance. I did not have health insurance at the time. I am unsure. What special skills, perspectives, experiences can you bring to this work?(Required)0 of 1000 max charactersPlease tell us what Reproductive Justice and Intersectionality in abortion access means to you.(Required)0 of 1000 max charactersWhat are your thoughts and feelings about abortion? If you feel comfortable, please share any personal experience you may have had with abortion care.(Required)0 of 1000 max charactersPlease list any current or previous volunteer roles, including names and location of the organizations(Required)0 of 1000 max charactersDriver's License Number(Required)Do you have reliable access to a car?(Required) Yes No Please check your ideal availability throughout the current year. Select all that apply.(Required) 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 This information is not set in stone. You will be able to update it as your situation changes, and we will reach out to you from time-to-time to make sure everything is still current. What is the maximum number of miles you are willing to drive round-trip?(Required)Please enter numbers only. We locate volunteers based on the number of miles from the caller and/or clinic. Can a caller bring a friend, partner or child with them?(Required) Yes No Do you have access to a child's car seat?(Required) Yes No If you answered "Yes" to having a car seat, please check all that apply below.(Required) Rear facing Forward facing Booster with back Booster without back Weight restrictions Can people smoke in your car?(Required) Yes No Describe your vehicle (year, make, model, color)(Required)Car insurance info (carrier, policy number)(Required)ReferencesPlease provide two references below: (1) professional, either coworker or supervisor, (2) personalReference 1 Name(Required)Reference 1 Relationship(Required)Please describe.Reference 1 Phone and Email(Required)Reference 2 Name(Required)Reference 2 Relationship(Required)Please describe.Reference 2 Phone and Email(Required)
