Date __________ Name __________________________ Signature _________________________

Address_________________________________ City ______________ State ____ ZIP ________

Telephone #   Home _______________________ Work _______________________

Birthdate (mm/dd/yyyy) ___/___/_____   Sex M ___ F ___   ODL#__________________________

e-mail address__________________________________________________

Emergency or Contact Person ______________________________Telephone #________________

Where did you hear about us? _______________________________________________________

How many hours can you volunteer per week? _______________

Would you prefer to volunteer

☐ set time (such as 8-12 every Wed) or  ☐ occasional time assignment?

Please indicate the days and times you have available to volunteer:

Mon ☐ AM ☐ PM

Tue ☐ AM ☐ PM

Wed ☐ AM ☐ PM

Thu ☐ AM ☐ PM

Fri ☐ AM ☐ PM

Sat ☐ AM ☐ PM

Number of hours per week: _________   Preferred days and time: _________________________

Personal References: (Not Relative)

  Name: __________________________ Telephone # __________________ Work # _________________

  Name: __________________________ Telephone # __________________ Work # _________________

As a volunteer, I realize that I play an important role in volunteer support services. I also realize that it is my responsibility to respect each person's privacy and maintain confidentiality.

 

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Signature		Date