I Want to Volunteer! Personal Data Date Name Date of Birth Address City State Zip Home Phone Cell/Work Phone Email Emergency Contact Name Emergency Contact`s Relationship to You Emergency Contact`s Phone Number Which local church do you attend? List skills, hobbies, interests, and education Previous or Current Occupation General Information How did you hear about the Samaritan Center`s volunteer program, and why do you want to volunteer here? Which days and times are you available to volunteer (list earliest to latest times)? Personal References Personal Reference #1 Name Home Phone Work Phone Relationship to You Personal Reference #2 Name Home Phone Work Phone Relationship to You Background Verification Have you ever been convicted of a criminal offense other than a minor traffic violation? No Yes Have you ever been charged with neglect, abuse, or assault? No Yes Has your driver`s license ever been suspended or revoked in any state? No Yes Do you use illegal drugs? No Yes Physical Limitations (Check all that apply) Sitting Standing Hearing Vision Allergies Did you have any lifting limitations? If so, please how many pounds can you lift? Please Enter Code Into the Textbox Below (code is case-sensitive):
I Want to Volunteer!
Personal Data
General Information
Personal References
Background Verification
Physical Limitations (Check all that apply)
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