Volunteer Application

Name *

Are you over 18 year old? *YesNo

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Employer (if applicable)

Do you have skills, special interests or experience that you would like us to consider when placing you into an appropriate position? *YesNo

If yes, please explain: *

Do you have any experience working with individuals with IDD (intellectual & developmental disabilities)? *YesNo

If yes, please explain: *

How many hours are you available per week?

Are you willing to volunteer weekends, evenings, & holidays?

Do you prefer mornings, afternoons, or evenings? *MorningAfternoonEveningAny

Do you have any physical limitations? *YesNo

If yes, please explain: *

Emergency Contact *

Emergency Contact Phone *

Relationship to you? *

References

Reference #1 *

Reference #1 Phone *

Reference #1 relationship to you? *

Reference #2 Name *

Reference #2 Phone *

Reference #2 relationship to you? *

Reference #3 Name *

Reference #3 Phone *

Reference #3 relationship to you? *

Have you ever been arrested for or convicted of a crime, felony or Misdemeanor (including violent or sexual based crimes)? *YesNo

If yes, please explain: *

By checking this box you agree to the above statement.

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