Volunteer Form Salutation--None--Mr.Ms.Mrs.Dr.Prof.Mx. First Name Middle Name: Last Name Preferred Name: Pronunciation: Profession Company Hourly Rate: Phone Secondary Phone: Primary Email Secondary Email: Street City Primary County:--None--Allegheny, PAArmstrong, PAAtlantic, NJBedford, PABerks, PABlair, PABucks, PABurlington, NJButler, PACamden, NJCape May, NJCarbon, PACecil, MDCentre, PAChester, PAClearfield, PAColumbia, PACumberland, PADauphin, PADelaware, PAErie, PAEssex, NJFayette, PAFranklin, PAGloucester, NJHartford, CTHoward, MDHudson, NJHunterdon, NJHuntingdon, PAKent, DELackawanna, PALancaster, PALehigh, PALuzerne, PALycoming, PAMercer, NJMiddlesex, NJMifflin, PAMonmouth, NJMonroe, PAMontgomery, PAMontour, PAMorris, NJNassau, NYNew Castle, DENorthampton, PANorthumberland, PAPerry, PAPassaic, NJPhiladelphia, PAPike, PAQueens, NYSalem, NJSchuylkill, PASnyder, PASomerset, PASusquehanna, PAUnion, PA,NJWayne, PAWest Chester, NYWestmoreland, PAWyoming, PAYork, PA-Out of Region- Zip State/Province Country Birthdate: We strive to offer programs and services that resonate with the full diversity of the communities we serve. We are asking the following questions to help us ensure that we are meeting this goal. Please note that responses to these questions have no bearing on your eligibility for services and that the data collected will only be used in the aggregate; individual applicant's answers to these questions are confidential. Which of the following best describe you?--None--WomanTransgender WomanManTransgender ManNon-binaryPrefer to self-describePrefer not to answer Gender Self-description: I identify as:--None--African AmericanAsianAsian AmericanBlack AfricanHispanic, Latinx or Spanish originMiddle Eastern or North AfricanMixed Race/Multi-RaceNative American/Alaskan NativePacific Islander/Native HawaiianWhite/EuropeanPrefer to self-describePrefer not to answer Race Self-description: How would you describe your sexual identity:--None--AsexualBisexualHeterosexual/straightHomosexual/gay/lesbianPansexualQueerQuestioningPrefer to self-describePrefer not to answer Sexual Identity Self-description: How do you describe your ability status?--None--I am living with a disabilityI am not living with a disabilityPrefer to self-describePrefer not to answer Are you a veteran?:--None--YesNoPrefer not to answer Languages:ArabicChineseFrenchGermanHaitianHmongItalianJapaneseKhmerKoreanLaotianMalayalamPashtoPolishPortugueseRussianSpanishUrduVietnameseOther Website Facebook: LinkedIn: Twitter: Available for:Full ServiceLegal ClinicOne-hour ConsultationReduced RateReferral ListSpeakers Bureau Speaker Bureau Experience:--None--JuniorSenior Practice Areas:Administrative/MunicipalArtist/Gallery AgreementsAuthor/Agency/Publisher RelationsBankruptcy: BusinessBankruptcy: PersonalBusiness: Contracts/PartnershipsBusiness: Small Business DevelopmentCensorship: BroadcastingCensorship: GeneralContract/ Agreement Review: GeneralContract/ Agreement Review: ManagementCopyright: GeneralCopyright: LitigationCollectionsComputer & Technology LawDefamationEntertainment: Contract ReviewEntertainment: Film/VideoEntertainment: InternationalEntertainment: LitigationEstate PlanningFamily LawGeneral PracticeImmigration: AsylumImmigration: Working Papers/Green CardInsuranceInternational (misc.)Labor/EmploymentLandlord/Tenant RelationsLitigation: GeneralNonProfit LawNonProfit IncorporationPatentProduct LiabilityReal Estate: CommercialTaxes: CorporateTaxes: IndividualTaxes: NonprofitTrademark, Service MarkTrade SecretTrusts & Estate Law Bar ID Number: Date Admitted to BAR: States Admitted Bar:ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Law School: Do you carry professional liability insurance? By submitting this application you acknowledge that the aforementioned information is true and accurate to the best of your knowledge and you further agree to the following: (a) pro bono clients are entitled to the same standard of care and protections of the attorney-client relationship as are paying clients; (b) I will not accept a matter referred to me by PVLA if the referral could result in a conflict of interest; (c) I will track hours spent in pro bono work for PVLA-referred matters and will provide this and billing rate information to PVLA for general reporting purposes upon request; (d) I will inform PVLA promptly regarding a change in contact information, attorney license status, PVLA volunteer status, practice areas or employment. Agree All Terms:
