® BRAILLE INSTITUTE VOLUNTEER APPLICATION (Please Print) Name: ___________________________________________________ Birthday: _________ /______ Last First Middle Month Day Mr. Ms. Mrs. Miss Dr. (circle one) Address: _______________________________ ______________________ ____ ________-____ Number and Street City State ZIP Code Phone: _________________________ _________________________ ______________________ Circle Primary (home, cell, or work) Circle Secondary (home, cell, or work) Circle Third (home, cell, or work) E-Mail: ___________________________________________ May we contact you by E-Mail: ______ Referred By: _______________________________________ Phone:________________________ Personal Reference: __________________________________ Phone: ______________________ Emer. Contact: ______________Relationship:__________ Phone 1:____________ 2:____________ DO YOU HAVE VOLUNTEER EXPERIENCE? Organization: ________________________________________ From – To: ___________________ Position: _________________________________ Supervisor: ______________________________ Duties: _________________________________________________ Phone: __________________ EMPLOYMENT (most recent): Company: _____________________________________ From – To: _______________________ Position: _______________________________________ Supervisor: _______________________ Duties: _______________________________________ Phone:___________________________ EDUCATION: High School: ______________________________ Highest Grade Completed ________ College(s): ________________________ Major __________ Minor ___________ Degree______ ____________________________________ Major __________ Minor ___________ Degree______ Languages: _______________________________________ (note whether fluent or conversational) WHY WOULD YOU LIKE TO VOLUNTEER AT BRAILLE INSTITUTE? What do you expect from the experience, and what can Braille Institute can expect from you? _________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Length of Commitment:__________ Day(s) available:___________ Hours available:____________ (PLEASE COMPLETE BACK SIDE OF PAGE)

Circle your interests: Creative Arts: Basketry, Ceramics, Crochet, Gardening, Jewelry, Knitting, Woodcraft Humanities: Creative Writing, Current Events, Health, Aging, Humor, Literature, Music Independent Living Skills: Cooking, Sewing, Home or Personal Management Languages and Codes: Spoken Languages, Braille, Sign Language Physical Education: Dance, Golf, Walking, Yoga Library: Circulation, Talking Book Machine Repair, Assisting clients with book selections Reading: Reading directly to patrons, Narrating (Recording or TRP Program) Reception / Clerical: Data Entry, Filing, Phones, Welcome Visitors Technology: Computer, Graphic Design, Tactile Graphics, Audio / Video Editing, Photography Miscellaneous: Driving, Lunch Guides, Other ________________________ Signature__________________________________ Date _____________________ Reviewer__________________________________ Date _____________________

For Internal Use: Start Date: __________ Date Entered ___________ Core ____ Intern ___ School _________________________ Volunteer #_____________ Driver ____ Youth ____ BI Student _____ Mail Code ____

Position Code Day(s) Time ___________________________ ________ ________ ___________ ______________________ _______ _______ _________ ______________________ _______ _______ _________ ______________________ _______ _______ _________ ______________________ _______ _______ _________ Skills: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ Comments: ______________________________________________________________________________________ _______________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Revised July 2009