Volunteer Application

Intake Form

Introduction/Description

Please complete the intake form below to create your JLB profile. If you have any questions, please contact Rebecca Hartsough at admissions@jlbonline.com.

Name

Title

First Name

Middle Name

Last Name

Suffix

Address

Address Type

Country

Street Address

Apt/Suite

City

State

Postal Code

County

Contact Information

Home Phone

Work Phone

Cell Phone

*One phone number is required

*Please enter a phone number as ###-###-#### or ###-###-####x####

**For international numbers add "+" before the number

Statistical Information

Date of Birth (mm-dd-yyyy)

Create Your Account

Username must be at least 6 characters long and conform to the following criteria:
lowercase and uppercase letters,
digits 0 through 9,
and these special characters: . @ + - _.

Passwords shall be a minimum of eight (8) characters in length and be comprised of three of the following four groups of characters: Uppercase letters, lowercase letters, numerals, and special characters

Username

Password

Verify Password