Volunteer Application

General Information

Name:				Date:
Mailing Address:
Home Phone:			Work Phone:
E-mail Address:			Birthday (Month/Day):
In accordance with state law, we are required to ask the following: Have you ever been convicted of a crime? YES NO If YES, please give details and date of conviction.
Are there any tasks that you may be unable to perform given any health conditions that might limit or impact your ability to do so?
Emergency Contact:	Name:	Phone:			Relationship:

Skills and Interests

Tell us briefly why you want to volunteer for INTERAC.

Educational Background:

Profession (Current or Previous):

Hobbies or Skills:

Previous Volunteer Experience:

Community Affiliations:

Second Languages:

Computer Skills:

Availability

At what times are you able to volunteer? (Please list All the hours that you are available, i.e. 2-4pm?)

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

Can you volunteer regularly each week? YES NO

How many hours each week do you want to volunteer?

Can we call you at the last minute? YES NO

Because many volunteer positions require training as a cost to INTERAC, we need volunteers who are committed to working with us on a consistent basis. Can you make at least a 6-month commitment?

YES NO

If NOT, what time commitment can you make?

References (Other than family members):

Name:

Relationship:

Address:

Phone Number:

Signature of Agreement:

I understand that all services and records are confidential and that confidentiality will be maintained in all cases unless mandated by law. I pledge to keep all client and contributor information confidential. Any volunteer who violates client or contributor confidentiality is subject to immediate dismissal. Confidentiality extends beyond volunteering with INTERAC.

I understand that in some cases, INTERAC may be required to perform a thorough investigation of past empl,oyment, education, criminal record, and motor vehicle driving record. I authorize INTERAC to perform any such investigation, in its descretion, as it relates to volunteering with INTERAC.

I understand that any false, misleading, incorrect or incomplete answer made by me in this application will be considered sufficient cause for denial of a volunteer position.

I understand that attendance at training sessions is required. Exceptions may be made in rare instances by the Volunteer Leader.

I understand that either myself or INTERAC reserves the right to end a volunteer’s relationship with this agency at any time.

Signature:

Date:

Return to Volunteer Page

INTERCOMMUNITY ACTION, INC. VOLUNTEER APPLICATION

General Information

Skills and Interests

Availability