Volunteer Application
Name
Address
City
State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
Home Phone
Work Phone
Best time to call
Education
Experience
Clerical Work
Counseling
Child Care
Teaching
Building Maintenance
Health Education
Public Relations/Media
Visual/Fine Arts
Fund Raising
Computers (specify below)
Other (specify below)
Reference Name 1
Phone 1
Reference Name 2
Phone 2
Why do you want to volunteer?
What are your interests?
(Pick top 2)
Beds & Britches
Clerical Work
Clinical Work
Outreach
Patient Reminder Calls
Reach Out and Read Mentor
Special Mailings
Other (specify below)
Rate each item that you wish to accomplish on the scale below.
very
unimportant
very
important
Gain Leadership Experience
Help Others
Learn/Develop Skill
Meet New People
Other
(specify below)
Minimum hours per week
Maximum hours per week
What times are you available?
Mon: Tues: Wed: Thurs: Fri: Sat:
How did you hear about our Volunteer Program?