Charles Lea Center : Get Involved : Volunteer Opportunities : Volunteer Application

Volunteer Application

Printable Volunteer Application

Volunteer Information and Health History Form

General Information

Name:

Gender:

	Male
	Female

Social Security Number:

Date of Birth:

Address:

City, State, ZIP:

Home Phone:

Work Phone:

Mobile Phone:

Pager:

Email Address:

Best day(s) and time(s) to contact you:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relation:

Parent/Legal Guardian Name and Address (if minor):

EDUCATION

What is the highest level of education you received:

Do you have any special skills you feel you could bring to the Center:

How did you learn about The Charles Lea Center:

Have you ever worked with individuals with disabilities? If yes, please explain. :

Have you ever been convicted of a crime? If yes, please explain.:

PHOTO RELEASE

I hereby DO or DO NOT :

	Do
	Do Not

Consent to and authorize the use and reproduction by The Charles Lea Center, Inc. of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Are you retired:

	Yes
	No

Current Employer:

Position:

Phone:

Length of Employment:

Past Employer:

Position:

Phone:

Length of Employment:

VOLUNTEER EXPERIENCE AND TRAINING

(If you have volunteered at another organization)

Organization #1:

When:

How Long:

Your Duties:

Organization #2:

When:

How Long:

Your Duties:

Organization #3:

When:

How Long:

Your Duties:

REFERENCES

(Please provide complete addresses for all references listed)

Reference #1 Name:

Phone:

Relationship:

Address:

City, State, ZIP:

Reference #2 Name:

Phone:

Relationship:

Address:

City, State, ZIP:

References #3 Name:

Phone:

Relationship:

Address:

City, State, ZIP:

BACKGROUND INFORMATION

(Please answer the questions below as completely as possible.)

Do you have any physcial disabilities that may affect or limit your work:

	Yes
	No

If yes, please describe:

Are you on any medication(s) and/or under medical supervision:

	Yes
	No

If yes, please describe:

Have you ever been convicted of a felony:

	Yes
	No

If yes, please describe:

GENERAL QUESTIONS

How did you hear about our employment opportunities:

What interests you in employment with us:

What foreign language do you speak fluently:

CERTIFICATION OF APPLICANT

By submitting this form, you certify that your answers on this application are true and complete to the best of your knowledge. You also grant your permission and consent for us to contact the necessary resources and references to verify your responses on this application.

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