Name:

Phone number:

E-mail address:

Current address:
 

City:     State:     Zip:

Emergency contact name:    

Emergency contact phone:

I. Skills and Interests

Education background:

Current occupation:

Hobbies, Interests, Skills:      

Previous volunteer experience:

Is there a particular type of volunteer work you are interested in? (Check all that apply)

Working directly with a staff person as an assistant      Working one on one with a single client

Doing research, teaching or an individual project           Providing a service to several clients

Helping with general administrative office duties            Doing public speaking, etc.

No preference                                                           

Other:

Is there a person or group you are particularly interested in working with? (Check all that apply)

Adults     Seniors    Teens    Children    Agency staff

Males      Females  No preference 

Other:

Are there any groups you are not interested in working with? (Check all that apply)

Adults     Seniors    Teens    Children    Agency staff

Males      Females  No preference

Other:

Why are you interested in volunteering with our organization?

II. Availability

How often would you be interested in volunteering?  Weekly    Monthly

Are you interested in volunteering for a specific time period?  Yes     No

If yes, please specify:

When are you available to volunteer?

  Am flexible    Prefer weekdays    Prefer evenings    Prefer days     Prefer weekends  

Do you have a preference as to where you do volunteer work?   Yes  No

If yes, please select a location:

Administrative Annex, 2388 Grandview Drive, Fort Mitchell

Administrative Office, 610 Medical Village Drive, Edgewood

Boone County Health Center, 7505 Burlington Pike, Florence

Campbell County Health Center, 1098 Monmouth St., Newport

Environmental Health and Safety, 610 Medical Village Drive, Edgewood

Grant County Health Center, 234 Barnes Road, Williamstown

Kenton County Health Center, 2002 Madison Ave., Covington

In the community

Do you have access to a vehicle you can use for volunteer work?  Yes No Occasionally

III. References

How did you hear about us?

Advertisement                        From client of agency

Referred by friend/volunteer      Other:

List name and phone number of two personal references:

Name:      Phone:

Name:      Phone: