Volunteer Application


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Date:

Volunteer Application Part I

Level II & III Volunteers Only

Personal Information Name: ___________

______ __________________ _________________

Address: _____________________________ _

________

_____________

City, State, Zip _______________________________________ Home Phone: _________

________ Work Phone: ______

___ _____ ______ ________

School / Church / Group Name (if applicable) _________________________ ______ Why are you interested in volunteering for MSHV? ___________________

__ _

Education Education completed: _____ High School _____ College _____ Other Are you currently in school? ___Yes ___No If yes, where? _____________

___

Emergency Information Please list two emergency contacts: Name: _____________ _____ ____________Relationship__________ __ __ Home phone: ________ _ _ ________Work phone: ______________ _ ____ Name: _______________________ ______ __Relationship_______ _____ Home phone: _____________ ______Work phone: ______ ___ ___________

Availability Please circle the days that you are able to volunteer: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time available (please circle): Morning Afternoon Evening

Other:

____ ______

Employment Are you currently employed? _____Yes _____No ____Retired If yes, where? __________ _________ ___ Type of business: _________________ ___________________________________

Revised 4/6/2016

Date:

Part II

Medical History Do you have any physical limitations that MSHV should be aware of? ___Yes ___No If so, what are they? _______________________________________ __________

Additional Information Have you ever been convicted of a felony? ____ Yes ____no If yes, please explain: ________________________________

___

References Please list two references: Name ____________________________________ Phone ____________________ Name ____________________________________ Phone ____________________

Staff Only: Phone references: __________ (date) Name of Staff: ___________ __ Written references: __ ______

Areas of Interest What skills do you have that you feel might be of value to MSHV?

What are your hobbies, interests or recreational activities?

________________________________________ Print Name

_______________________ Date

________________________________________ Signature

Please return your completed application to our Freedom Commissary/Volunteer Coordinator, John Dixon 433 S. Carlton Avenue Wheaton, IL 60187 [email protected] Fax: 630-871-8387 ext. 617

Revised 4/6/2016