2015 Conference Volunteer Registration

Volunteer Application
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information:
Emergency Contact Name:

First NameLast Name
Emergency Contact Email:
example@example.com
Emergency Contact Phone Number:

Area CodePhone Number
Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any medical conditions that we should be aware of in case of an emergency or that would affect your placement?

YesNo
If yes, please explain:
Education, Volunteer Experience, and Employment
Highest Level of education completed:
Previous Work Experience:
Current Employer:
Approximately how many hours per week do you work?
Previous or current volunteer experience:
What areas would you like to volunteer for?*

Out & About (recreation, going out to eat, movies, etc.)Suzie Cappa Art CenterFlutter Productions (All-Ability Theater)Person Centered One-on-One'sLearning Institute (Classes, Room & Individual Supports)BakeWorks (Bakery Support)Special Olympics (Softball, Basketball, Swimming, Track & Field, Etc.Event Support (Gala, Putt-N-Pub)Other
What are your hobbies, interests, and skills:
Availability

Long-TermShort-TermSpecial Event
Date available to begin volunteering:

MonthDayYear
Date
What days and times are you available to volunteer? Check All days that apply

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
How many hours per week are you interested in volunteering?
Legal Information and Volunteer Release

**Necessary only if Volunteer is 18 years of age or older

I understand and with my signuture authorize the agency to conduct a criminal background check and checks agains the federal governments. Background checks are Required for all applicants 18 years and older.
Name

First NameMiddle NameLast Name
Any other names you have used in the past
Date of Birth

MonthDayYear
Date
SSN:
Electronic Signature

Clear
Have you ever been convicted of a crime?

YesNo
If yes, please explain:
Have you ever received a traffic citation/violation, other than a parking ticket?

YesNo
If yes, please explain:
Are you volunteering to fulfill a community service requirement?

YesNo
If yes, please list name(s) of person/institution requiring service and number of hours required:
After you click Submit, you will be contacted by our volunteer coordinator with the details of your application.
Should be Empty: