Apply to Volunteer

Personal Information

Name

Address

Phone

County of service

Community Service Information (If you are applying to complete community service hours, complete this section

Referral Agency

Contact Name

Phone Number

Charges (If any)

School Contact Information (If you are applying for an intern position, complete this section)

Referring School

Contact Name

Address

Phone

Volunteer Availability

Start Date

End Date

Monday

Tuesday

Wednesday

Thursday

Friday

Satruday/Sunday

Reference Information

Reference 1

Name

Address

Phone

Reference 2

Name

Address

Phone

Reference 3

Name

Phone

Address

Emergency Contact Information

Name

Address

Phone

Alternate Phone

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted for community service, as an intern or volunteer, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal. Also, by signing, I am this application; I am providing consent for all references to be contacted.

Signature

Date

Personal Information

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