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Volunteer Application

Contact and Personal Information

* Required

Name

First * Last *

Address

Street Address

Address Line 2

City State / Province / Region

Postal / Zip Code

Country

Other

Phone Number * (###-###-####)

Email *

Date of Birth

Drivers' License # / State / Expiration Date

Availability

During which hours are you available for volunteer assignments?

Weekday Mornings Weekend Mornings Weekday Afternoons Weekend Afternoons Weekday Evenings Weekend Evenings

Interests

For which program(s) are you interested in volunteering?

Computer Training The Treasure Shop Music Programs Resident Activities Grounds Maintenance Personal Visits

Criminal Background Information

Have you ever been convicted of a felony?

Yes No

If yes, please explain:

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.

General Health

Do you have any health problems that would limit your participation in certain activities? Please explain.

Person to Notify in Case of Emergency

Emergency Contact Name First Last

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Emergency Contact Phone Number ###-###-####

Emergency Contact Email

Professional or Personal References

Please list 2 complete references—Name, Complete Address, Phone, Email Address.

Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Our Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.