CONTACT INFORMATION Full Name * Street Address * City, State, ZIP * Contact Phone * Alternate Phone E-Mail Address * Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007 Are you retired? * Yes No AVAILABILITY There is a four-hour weekly minimum commitment required to volunteer at Helen's Hope Chest. Are you able to meet this commitment? * Yes No During which hours are you available? (Check all that apply) * 9:00am - 1:00pm 12:00pm - 4:00pm Monday Monday - 9:00am - 1:00pm Monday - 12:00pm - 4:00pm Tuesday Tuesday - 9:00am - 1:00pm Tuesday - 12:00pm - 4:00pm Wednesday Wednesday - 9:00am - 1:00pm Wednesday - 12:00pm - 4:00pm Thursday Thursday - 9:00am - 1:00pm Thursday - 12:00pm - 4:00pm Saturday Saturday - 9:00am - 1:00pm Saturday - 12:00pm - 4:00pm Morning shift: We will need you in the building by 8:45 am to prepare for appointments. Afternoon shift: We may need you to stay a few minutes after 4 pm to finish up our final appointment of the day. STUDENT INFORMATION (if applicable) Are you volunteering for service learning? * Yes No Date hours need to be completed by Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Number of hours required Instructor College or university Degree major Graduation month and year Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2017201820192020202120222023 EMPLOYMENT (if applicable) Employer Name Occupation Description Years with company Phone Number May we contact you at work? Yes No SPECIAL SKILLS OR QUALIFICATIONS Summarize special skills and qualification you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. Special Skills and Qualifications AGREEMENTS & BACKGROUND Do you have any physical limitations that may inhibit your ability to work at Helen's Hope Chest? * Yes No Do you have any health concerns that we need to be aware of? (epilepsy, etc.) * Yes No Have you ever been convicted of a crime? * Yes No If yes, please explain Are you currently awaiting trial? * Yes No If required, would you be willing to authorize a background check? * Yes No Are you bilingual? * Yes No If yes, in which languages are you fluent? PERSON TO NOTIFY IN CASE OF EMERGENCY Full name * Home Phone * Cell Phone Relationship * TERMS & CONDITIONS By checking "I Agree" below, entering my name, and submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I also understand I will be expected to follow established policies and procedures, with a mutually accepted work schedule of which I will adhere. Inability to maintain the work schedule may result in immediate dismissal. I Agree * Yes No Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 OUR POLICY It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. A background check will be performed on each application to ensure a safe working environment for our families, staff, and volunteers. We thank you for your understanding in this matter. Thank you for completing this application form and for your interest in volunteering with Helen's Hope Chest.