8/12/2019 KYCC Volunteer Intake Sheet 000
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VOLUNTEER INTAKE SHEET
Name: Check here if you are a High School student.Address:
Contact Phone: ( ) -City/State/i!: "mail: References (Other than
family)
Name: Name:#elationshi!: #elationshi!:Phone Num$er: ( ) - Phone
Num$er: ( ) -Address: Address: City/State/i!: City/State/i!:SKILLS
(Check all that aly)!
%eaching/%utoring/Child Su!er&ision: S!ecial "&ents/
'undraising
Preschool arketing/ Pu$lic #elations
rades *-+ ,anguage(s) S!oken:
High School outh ,anguage(s) %ranslation:
Clerical (ata "ntry 'iling etc.) %echnology (0e$ Com!uter Skills
etc.)
"n&ironmental Ser&ices (%ree Planting raffiti
#emo&al Street Clean-u!s etc.)
S!eciali1ed Skills:
CERTI"ICATIONS!
CP#/'irst Aid (Check those that apply: 2nfant Child Adult)
Proof of Clearance: %3 'inger!rinting (required for any
volunteer hours with youth)
4ther certifications:
AVAILA#ILIT$! (Please indicate s!ecific times and days you 5ould
like to &olunteer. %lease n&te that K$CCre'ires *eeks
t& r&cess all +&lnteers,)
Are you &olunteering to fulfill a ser&ice commitment6 es
No
2f yes ho5 many hours do you need to fulfill6 $y / /
(mm/dd/yy).Ho5 many hours you 5ould like to &olunteer6 !er 5eek
!er month !er year
Hours A&aila$le: (Pro&ide e7act dates if kno5n)
onday %uesday 0ednesday %hursday 'riday Saturday Sunday Not
a&aila$leC"#%2'2CA%24N and A8%H4#2A%24N ("&rm cann&t -e
r&cesse. *ith&t a si/natre,)
2 certify that the information !ro&ided in the 9olunteer
2ntake Sheet is true correct and com!lete. 2 authori1e
&erification of all statements contained in this 2ntake
Sheet. 2 authori1e former em!loyers and/or educational
institutions to !ro&ide information concerning me and 2 release
them from lia$ility for !ro&iding any such
information to the *oreato5n outh Community Center.
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H#sak
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FOR OFFICE USE ONL!
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