Prefix Last Name First Name Middle Name
 

Spouse’s Name

   Maiden Name
   
Street Address    

Apartment Number
City   State Zip Code
Cell Phone Fax Number Education Major

Employment Information
I am My employer offers
Employer Name Your Occupation    
City State

Department/Suite Number

 Work Phone
  Zip Code  

Supervisor’s/Counselor
   

Ok to Recive calls at work

 Social Security Number Driver’s License
   

Criminal Record Check
       
Have you ever been convicted of a felony or misdemeanor? YesNo  
Are you currently charged with a felony or misdemeanor?    YesNo  

Answering yes does not exemt you from volunteer services but relevant factors will be evaluated.

       

References:  Please list three people other than relatives who would be willing to serve as personal references.
       
Last Name First Name  

Relationship
 
Address City State Zip
Home Phone

Work Phone
       
Last Name First Name  

Relationship
 
Address City State Zip
Home Phone

Work Phone
       
Last Name First Name  

Relationship
 
Address City State Zip
Home Phone

Work Phone
       
Last Name First Name  

Relationship
 
Address City State Zip
Home Phone

Work Phone
       

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING YOUR NAME IN THE SPACE INDICATED.

  • I certify that the statements made in this volunteer application are true and correct, and have been given voluntarily. 

  • I understand that this information may be disclosed to any party with legal and proper interest, and I release the agency from any liability whatsoever for supplying such information.

  • I agree that any written or oral misrepresentation in making this application is just cause for dismissal. 

  • I hereby authorize references listed on this application to answer any questions and to furnish any accurate information from their records concerning me, and I hereby release such companies and persons from any liability for such action.

  • I understand that I will not be paid for my services as a volunteer.
     
  Name Date  
I accept  
       

Medical Information
       
Do you have any medical conditions that would affect your ability to perform your volunteer duties, or that the volunteer office should be aware of?Yes No
       

Availability

Please enter the times you are usually available for a volunteer assignment:
       
Sunday Monday Tuesday Wednesday Thursday Friday Saturday  
 
       

Statistical Information 
 The following information is for statistical analysis only.
       
Brith Date Gender Marital Status Race
MaleFemale Married Single CaucasianHispanic
      African-American
      Asian         Other

How did you first hear about WMPN Volunteer Opportunities?

  
       

 

 Special Skills, Training/Experience, Talents   Please check all that apply:		  
       
Spanish speaking Business/Banking Marching Drills Clergy/Ministry
Math/Science Education Newsletter/Written Communication  Photography
Law Enforcement/Judicial Office/Clerical/Computer Media/Newspapers Medical/Medicine
Public Speaking Military Background Arts/Drama/Dance Musical Ability
Counseling/Social Work Sales/Marketing Sports/Athletic Fundraising

Certifications/Licenses

Other skills, training, and talents
       

Your Preferences for Volunteer Work        Please check all areas that you are interested in serving:
       
Mentor/Youth Advisor Tutor Volunteer Advisory Council

Other
Educational Aide Fundraising Group Leader (Support/Education)