Volunteer Application

Your Full Name (first, middle, last)*

Email Address*

Phone Number*

Address (Street, City, State, Zip)

Date of Birth (must be 18 or older)*

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact's Relationship to You*

Why are you interested in volunteering with us?

What days are you available to volunteer? What days are you available to volunteer? Monday Tuesday Wednesday Thursday Friday

What times are you available to volunteer? What times are you available to volunteer? Morning (8 AM - 12 PM) Afternoon (12 PM – 3:30 PM) Full Day (8 AM – 3:30 PM)

What types of activities would you like to assist with? What types of activities would you like to assist with? Social Activities (e.g., games, crafts, music) Meal Assistance Transportation Assistance Special Events Office/Admin Work Other (please specify) Work

Do you have any special skills or certifications? (e.g., CPR, First Aid)

Are you willing to undergo a DHS background study? (No cost to you) Are you willing to undergo a DHS background study? (No cost to you) Yes No

Do you have a valid driver's license? Do you have a valid driver's license? Yes No

Reference #1: Please provide a reference (non-family members) we can contact. Must include: Name, Phone Number, and Relationship.

Reference #2: Please provide a reference (non-family members) we can contact. Must include: Name, Phone Number, and Relationship.

By submitting this application, I certify that the information provided is true and complete to the best of my knowledge. I understand that I may be required to undergo a background check before beginning volunteer service. By submitting this application, I certify that the information provided is true and complete to the best of my knowledge. I understand that I may be required to undergo a background check before beginning volunteer service. Yes

Your Signature (type your full name here):

Today's Date: