Volunteer Application - themainplaceirving.org

First Name *

Maiden Name

Last Name *

Home Address *

City *

Zip Code*

E-mail Address*

Cell*

Text? *

Yes No

Race/Ethnicity

Other Race/Ethnicity

Date of Birth *

Social Security Number (SSN)*

*

Male Female

Place of Employment or School*

Employment Postion or Grade*

Emergency Contact

Emergency Contact Cell#

Will you be volunteering as

Individual Group

Group Name

Do you have any previous volunteer experience?*

Yes No

If yes, Where?

Volunteer Date(s)

Volunteer Role

Please list community organizations to which you belong

Community Organization Role

Member Committe Chair Board Member

What three causes or social issues most concern you and why?*

Skill or Experiences (Check all that may apply) *

Other Skills or Experiences *

Other Languages

Do you have any physical limitations? *

Yes No

If yes, please describe

Current Schedule (Please Check your availability)

1st Thursday, 5 pm - 8 pm 2nd Wednesday, 5 pm - 8 pm 2nd Saturday, 9 am - 12 pm 4th Wednesday, 5pm - 8 pm 4th Saturday, 9 am - 12 pm Each Wednesday, 10 am - 2 pm

Permission*

I grant permission for The Main Place to use photographic or video images taken of me durig volunteer work and events for use in media or other pbulications in rleation to The Main Place porgrams, and to which copyright of these images will be held by The Main Place. I grant permission for The Main Place to add my email to their mass email distribution list. The Main Place does not sell or share your personal information. After being added to the email list I understand that I can opt out at any time. I have given permission for CIA to do a background /criminal check. I agree to abide by the policies and regulations of The Main Place throughout my assoication with the agency. I understand that my association with The Main Place is by mutual agreement and that I am volunteer. I understand that confidentiality of client information and The Main Place affairs is mandatory and it is my ethical obligation as a volunteer to adhere to strict compliance, and any breach of confidentiality is reason for termination of any relationship with The Main Place as a volunteer.

Reference (1) Name *

Reference (1) Cell*

Reference (1) email*

Reference (2) Name *

Reference (2) Cell*

Reference (2) Email*

We cannot accommodate court appointed community service applications.