Full Name________________________________

Phone Number                                          email


Home Address


City,                             State                                           Zip

______________________________________    Yes or No _______________________

Employed By (If Employed)                                  Other                 Retired

How long have you lived at this address?  ________________________________

May you be called at work? {} Yes    {} No


Brief description of volunteer experience?

Formal Education (highest year completed):


Do you speak a foreign language?   {} Yes   {}  No   If yes, which language


Do you drive?  {}Yes   {}No     Do you have access to a good working vehicle that you would use to to get to and from locations with insurance {}YES or {}No

Current Community Involvement, if any.

Special Certification (i.e. CPR, Medical, etc.):   q  Yes    q  No

What type ____________________________________________________________________

Are you willing to commit to 3 6 or 12 months volunteer service?   {}Yes Or {}No

Which length of time? _______________

What are your reasons for wanting to participate with our non-profit?




Can you consent to a routine background check?  {}Yes Or {}No

Please list three references of people who know you well, other than relatives, preferably for whom you have worked in either a paid or volunteer capacity.  If you are currently working, either paid or as a volunteer, please include the name of your supervisor.

Name                                  Phone No.                                Relationship

  1. _________________________________________________________________________
  2. _________________________________________________________________________
  3. _________________________________________________________________________

All information obtained will be held in the strictest confidence.

_______________________________________   _____________________________________

Electronic Applicant Signature                                                     Date