Volunteers Welcome!

Wed, 05/12/2010 - 06:29 — rrussell

Faith in Action Steuben County
PO Box 117, Hornell, NY 14843
Hornell AREA (607) 324-1138
Corning AREA: (607) 936-0941

Volunteer Application

Personal Information:

Name: *

Phone (H): *

(W/C): *

Address: *

Email: *

Religious affiliation(optional):

Occupation: *

Date of Birth: *

Your preferred method to be contacted:

Email: *

Phone: *

Either:

If doing transportation, how far are you willing to drive?:

Long distance(50+ miles one way)

Local(20 miles or less one way)

In town(5 miles or less one way)

I can generally volunteer:

More than once a week

Once a week

Other:

Please indicate below if there are particular days/times you would like to serve (optional):

Volunteer/Care-Recipient Matching Information

General interests, skills, volunteer experience, languages, and hobbies::

Yes/no:

	Yes	No
Are you allergic to pets?
Are you a smoker?

(If so, we ask that you please refrain in the presence of our care-recipients. Thank you.)

Screening Information:

Note: Faith in Action requires a copy of your valid NYS Driver’s license and Insurance card to transport care-recipients. Please:

	yes	no
Do you have a driver’s license?

Type of Vehicle:

Car

Van

Truck/SUV

Have you ever been convicted for violation of any laws, traffic or otherwise?:

yes

If yes, please describe:

Do you have any physical condition that may limit your volunteer activities?:

yes

If yes, please explain:

Emergency Contact

Name:

Phone:

Relationship:

References

Please list three persons we may contact who are not family members. You may include employers, teachers, religious leaders, etc. Faith in Action will also complete a background check prior to beginning your volunteer service.

Name:

Phone:

Relationship:

Address:

Name:

Phone::

Relationship:

Address:

Name:

Phone::

Relationship:

Address:

I hereby give my consent for the Faith in Action to contact my references.

Signature of Applicant:

Date:

(If completing online, typed name/date will constitute assent)

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