Charles Lea Center : Get Involved : Volunteer Opportunities : 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

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

If yes, please describe

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

If yes, please describe

Have you ever been convicted of a felony

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.