Date:
Volunteer Application Part I
Level II & III Volunteers Only
Personal Information Name: ___________
______ __________________ _________________
Address: _____________________________ _
________
_____________
City, State, Zip _______________________________________ Home Phone: _________
________ Work Phone: ______
___ _____ ______ ________
School / Church / Group Name (if applicable) _________________________ ______ Why are you interested in volunteering for MSHV? ___________________
__ _
Education Education completed: _____ High School _____ College _____ Other Are you currently in school? ___Yes ___No If yes, where? _____________
___
Emergency Information Please list two emergency contacts: Name: _____________ _____ ____________Relationship__________ __ __ Home phone: ________ _ _ ________Work phone: ______________ _ ____ Name: _______________________ ______ __Relationship_______ _____ Home phone: _____________ ______Work phone: ______ ___ ___________
Availability Please circle the days that you are able to volunteer: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time available (please circle): Morning Afternoon Evening
Other:
____ ______
Employment Are you currently employed? _____Yes _____No ____Retired If yes, where? __________ _________ ___ Type of business: _________________ ___________________________________
Revised 4/6/2016
Date:
Part II
Medical History Do you have any physical limitations that MSHV should be aware of? ___Yes ___No If so, what are they? _______________________________________ __________
Additional Information Have you ever been convicted of a felony? ____ Yes ____no If yes, please explain: ________________________________
___
References Please list two references: Name ____________________________________ Phone ____________________ Name ____________________________________ Phone ____________________
Staff Only: Phone references: __________ (date) Name of Staff: ___________ __ Written references: __ ______
Areas of Interest What skills do you have that you feel might be of value to MSHV?
What are your hobbies, interests or recreational activities?
________________________________________ Print Name
_______________________ Date
________________________________________ Signature
Please return your completed application to our Freedom Commissary/Volunteer Coordinator, John Dixon 433 S. Carlton Avenue Wheaton, IL 60187
[email protected] Fax: 630-871-8387 ext. 617
Revised 4/6/2016