Adult Volunteer Application

Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.

* Denotes required field

*First name:

*Last name:

Middle initial:

Date of birth (mm/dd/yyyy):

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*Address:

*City:

*State:

*Zip:

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*Phone:

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*Email address:

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*Emergency contact name:

*Emergency contact phone:

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*Relationship:

*Physician's name:

*Physician's phone:

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List any medical or physical limitations:

*Did you complete high school?

Yes

*School name:

Other (College, Vocational, Technical, Professional, etc.):

*Employer(Last or present):

*Start date:

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End date (Leave blank if still employed):

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*Phone:

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*May we call you at work?

Yes

*Have you ever been convicted of a felony?

(A conviction record will not necessarily be a bar to volunteering.)

Yes

Do you need to volunteer to fulfill community service obligations?

Yes

If yes, how many hours?

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*Briefly describe your employment history:

Briefly describe any past volunteer experiences:

Reference 1

*Name:

*Relationship:

*Address:

*City:

*State:

*Zip:

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*Phone:

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Reference 2

*Name:

*Relationship:

*Address:

*City:

*State:

*Zip:

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*Phone:

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Availability

*Please describe your availability:

* The above information is accurate and correct to the best of my knowledge. I understand that failure to present accurate information may result in being excused from volunteer services.

By checking this box, you also are indicating your approval for us to check references and contact your physician regarding your physical and emotional health. This organization is not obligated to provide a placement, nor are you obligated to accept this position.