Volunteer Application

Personal
Emergency
Interests/Availability
Experience
References

Personal Information

Applicant Name*

Street Address*

City*

State*

Zip Code*

Phone Number*

E-Mail*

DOB*

Activity Level*

Limited Activity (requires mostly sitting)
Moderately Active (some walking)
Very Active (capable of walking distances and pushing wheelchairs)
Other

Reliable Transportation*

Yes
No

Have you ever been convicted, pled no contest, or had deferred prosecution? If yes, explain.*

Emergency Contacts

Name

Relationship

Phone Number

Experience

Have you ever done any voluntary work before? If yes, please tell us about the experience.

Skills or qualities you can use in your voluntary work

Do you have any second language skills? If yes, please describe skill level.

References

First Reference

Name

Relationship

Phone Number

E-Mail

Second Reference

Name

Relationship

Phone Number

E-Mail