Volunteer position title: Date:
Name:
Address:
City:
State: Zip:
Cell Phone:
Work Phone:
E-mail:
Previous Volunteer Experience:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Occupation (Past occupation if retired):
______________________________________________________________________
______________________________________________________________________
Other information that will help us makes a good match (such as
education, general
Interests/hobbies :) ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Languages Spoken:
Availability and Volunteer Assignment Preferences: Please Check All That Are Applicable:
I Am Available 口Mornings
(Mon-Fri) 口 Afternoons (Mon-Fri) 口Evenings (Mon-Fri)
口 Weekends 口Once A
Week 口More Than
Once A Week
口 One Time Only 口 As Needed 口OTHER
Do You Have a Valid (State) Driver’s License? 口Yes 口 No
License Number:
Vehicle License Plate Number:
Insurance Company:
Policy #:
Have You Ever Been Convicted For Violation of Any Laws, Traffic or
Otherwise?
口Yes 口No If Yes, Please Explain:
__________________________________________________________________
Do You Have Any Physical Condition that May Limit Your
Activities? 口Yes 口 No
If Yes, Describe:
______________________________________________________________________
Who to Notify In Case Of an Emergency?
Telephone Number:
References
Please list three persons we may call who are NOT family, one of
whom may be your religious or spiritual leader, teacher, employer or
relationship other than personal friend.
Name:
Email:
Address:
Relationship:
Name:
Email:
Phone:
Address:
Relationship:
Name:
Email:
Phone:
Address:
Relationship:
Comments:
I hereby give my consent to contact my references to contact my
employers, past and present and to conduct a background check.
_____________________________________ _____________
Signature of Applicant Date
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