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TODAY’S DATE:Name:Date of birth: Home Phone: Cell Phone:Current address:City: State: ZIP Code:Email:Employer’s Name/School’s Name:Education/Special Training:Occupation/Academic Major:Language(s) Spoken:
Agency: ____________________________________________________________________________________________________Dates of service:_____________________________________________________________________________________________Number of service hours:______________________________________________________________________________________
Please list any special talents you may have, such as painting, clerical skills, phone calling, gardening, etc:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Placement Preferences: Please indicate 1st, 2nd, and 3rd choice.______ 1. Special Events Volunteer______ 2. Peace For Kids Child Development Center Volunteer ______ 3. Family Program Volunteer______ 4. Our Lady of Perpetual Help Volunteer______ 5. St. Philippine Home Volunteer______ 6. Maintenance/Grounds Volunteer______ 7. Clothing/Donation Closet Volunteer______ 8. Other: ____________________________________________________________________________________________
Why would you like to volunteer at Queen of Peace Center?______________________________________________________________________________________________________________________________________________________________________________________________________________________
What would you like to get out of your volunteer experience at Queen of Peace Center?______________________________________________________________________________________________________________________________________________________________________________________
Duration of Volunteer Services:
One Time: _____ 1-3 months: _____ More than 3 months: _____ On-call:_____
Other: _________________________ to __________________________
Available Start Date: ______________________________ Proposed End Date: _______________________________
REFERENCES: Please list two people who would be willing to serve as personal references.
1. Name: ___________________________________________ Phone Number: ____________________________________
Street Address: _________________________________________ City:_______________________ State: ___________
Email Address: _______________________________________________
2. Name: ___________________________________________ Phone Number: ____________________________________
Street Address: _________________________________________ City:_______________________ State: ___________
Email Address: _______________________________________________
EMERGENCY CONTACT: In the event of an emergency, please list the person you would want notified.
Name: ___________________________________________ Phone Number: ____________________________________
Street Address: _________________________________________ City:_______________________ State: ___________
Email Address: _______________________________________________ Relationship: ____________________________________
Statement of Understanding:
I certify that all information is true and has been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest. I release the agency from any liability whatsoever for supplying such information.
I understand that I must be at least 18 years of age to volunteer at Queen of Peace Center.
Upon being offered a volunteer position, I understand that I may be required to provide additional information pertinent to the position for which applied.
SIGNATURESSignature of applicant: Date:Printed name of applicant: Date: