Volunteer Application

 

Personal Information:

 Name: ___________________________       Phone: (H): _____________(W):______________

Address:__________________________________________________  

Email:______________________________ 

Congregational affiliation: (optional)______________________________________

Occupation: _________________________________________________

How did you hear about the Shepherd's Center of Oakton-Vienna?_________________________

 

Volunteer Services of interest to you:

           ____friendly caller                           ____data entry/computer work                ____handy-helper

           ____medical driver                          ____fundraising                                       ____ grant-writing

           ____financial record-keeping          ____companion driver                             ____ yard work

           ____ program assistance                 ____board membership                          ____ office assistance

           ____ public speaking                      ____other:___________

 

Availability:

 Please check all that apply:

 

TIME/DAY	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
MORNING
AFTERNOON

 

Matching Information:

 General interests, skills, volunteer experience, languages, and hobbies:______________________ _______________________________________________________________________________

  

Screening Information:

 Do you have a valid driver’s license?     ____ yes          ____ no

            License number:    _______________________________

            Insurance number: _______________________________  Policy Number:________________

Have you ever been convicted for violation of any laws, traffic or otherwise?  _____yes _____ no

            If yes, please explain:___________________________________________________________

Do you have any physical condition that may limit your volunteer activities?  _____ yes _____ no

            If yes, please describe:___________________________________________________________

 

Emergency Contact:

 Name:________________________ Phone:________________ Relation:____________________

 

References:

 Please list two people we may contact who are not family members.  (You may include employers, neighbors, religious leaders, etc.)

 

Name:________________________ Phone:________________ Relation:____________________

 

Address:________________________________________________________________________

 

 

Name:________________________ Phone:________________ Relation:____________________

 

Address:________________________________________________________________________

 

 I hereby give my consent for the Shepherd’s Center to contact my references.

 

 

______________________________                           ________________

Signature of Applicant                                                    Date