Date: 

Name:

Phone(H):  Phone(W):

E-mail:

Address1:

Address2:

City:

State:

Zip:

Date of Birth:

How did you learn about volunteer opportunities at People Incorporated?

When are you available for volunteer service?

Check day(s) corresponding with available times.

How many hours do you hope to volunteer?

Per Week: Per Month:

Length of time you feel you can serve:

Please check the types of opportunities that interest you.

Please indicate your level of education:

Please list skills you hope to use in your volunteer work:

Why are you interested in becoming a volunteer at our agency?

What experiences have you had working with people with disabilities?

Are you fluent in any language other than English(including sign language)?
Please list:

Have you had a Mantoux test in the past year?

Yes: No:

Please list some of the organizations where you have been an employee or volunteer, and describe the type of work that you did there.

1. Organization:

From: To:

Address:

City: State: Zip:

Description of work:

Position Supervisor: Telephone:

2. Organization:

From: To:

Address:

City: State: Zip:

Description of work:

Position Supervisor: Telephone:

3. Organization:

From: To:

Address:

City: State: Zip:

Description of work:


Position Supervisor: Telephone:

People Incorporated requires that volunteers pass a criminal background check before beginning service.

Have you ever been convicted of a crime?

Yes No

If yes, please state the type of conviction
(The existence of a criminal record will not automatically disqualify you from being able to serve as a volunteer)

Please list three references (only one friend/relative please):

1. Name:


Relationship to you:


Organization/Company:


Telephone:

Address:

City: State: Zip:

2. Name:


Relationship to you:


Organization/Company:


Telephone:

Address:

City: State: Zip:

3. Name:


Relationship to you:


Organization/Company:


Telephone:

Address:

City: State: Zip:

Name of person to contact in case of an emergency:

Telephone: Day Evening

Address:

City: State: Zip:

By completing this form, I certify that the information provided in this application is true and complete to the best of my knowledge. I authorize People Incorporated to verify the information contained in this application and to investigate my personal and employment history.