Volunteer Application

Personal

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Last Name * First Name * Middle Name Address * City * State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip * Home Phone Cell Phone * Email * Occupation * Place of Employment Employment Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Employment Phone

Emergency Contact

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Name * Address City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Phone * Relationship

Volunteer Interests

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Subjects Grad Level Preference Other

At what times are you available to volunteer?

How did you learn about the Volunteer Program? Previous Volunteer Experience Experience with Children (professional, volunteer, personal) Special Interests, Skills, Hobbies Community Affiliations (Church, Religious, Professional, Social, Recreational, Civic Groups, Alumni, Organizations, etc.)

Education

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High School

Name City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Years Completed Diploma/Degree Received

College

Name City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Years Completed Diploma/Degree Received Courses of Study

Technical/Trade

Name City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Years Completed Diploma/Degree Received Courses of Study

Any other Education or Vocational Training

Name City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Diploma/Degree Received Courses of Study

References

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Reference #1 Email * Reference #2 Email * Reference #3 Email *

Authorization and Understanding

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I acknowledge and agree that I am not obligated, if called upon to perform the volunteer services herein applied for and that OrchardPlace is not obligated to assign or seek to assign me to a volunteer position.

I understand that as a part of the matching process, the agency professional staff will elicit additional personal information from me.

I certify that my statements are true, complete, and correct to the best of my knowledge and belief.

I hereby authorize Orchard Place to contact the references listed on the application form and to conduct whatever investigation it may deem necessary to determine if I can become an effective volunteer at the agency.

Signature *