Volunteer Application
About You
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Name:
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Date of Birth:
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E-mail Address:
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Primary Phone:
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Type:
Home
Cell
Work
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Mailing Address:
Secondary Phone:
Type:
Home
Cell
Work
*
Current/Most Recent Occupation:
Home Church:
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List any hobbies/skills/interests/education:
General Information
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How did you hear about the Samaritan Center's volunteer program, and
why would you like to volunteer here?
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What days and times are you available to volunteer?
In Case of Emergency
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Emergency Contact Name
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Contact's Phone Number:
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Relationship:
Spouse
Relative
Friend
Employer
Other
Personal References
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Reference #1 Name:
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Best Phone Number:
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Relationship:
Current Employer
Previous Employer
Teacher
Friend
Relative
Other
Reference #2 Name:
Best Phone Number:
Relationship:
Current Employer
Previous Employer
Teacher
Friend
Relative
Other
Background Verification
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Have you ever been convicted of a criminal offense, other than a minor traffic violation?
No
Yes
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Have you ever been charged with neglect, abuse, or assault?
No
Yes
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Has your driver's license ever been suspended or revoked in any state?
No
Yes
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Do you use illegal drugs?
No
Yes
If you have answered yes to any of the above questions, please explain:
Physical Limitations
Please check all that apply:
Sitting
Standing
Hearing
Vision
Allergies
If you have lifting limitations, please let us know the maximum number of pounds you are able to lift:
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Indicates Response Required
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