Community Service Form
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2Office Use only:
Orientation Date: ____________________
Interest Forms: __________________________________________
Eastside neighbors Growing in Community
Community Service Form
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___________________________ _______________
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Date
Last Name
M.I.
First Name
Gender
Birthdate
________________________________________________________________ ______________________ _______________ ______________________
Address
City
State
Zip Code
____________________________
____________________________ ____________________________________________________________________
Home Phone
Cell Phone
Email
_________________________________________________________
_______________________________
Emergency Contact
Phone
Court Appointed Contact
List the name and phone number of your assigned court appointed contact. Court paperwork concerning your court
assignment, deadlines, and other requirements or related information must be attached to be considered for volunteer.
Name of Court: __________________________________________________________________________________
Contact Person:__________________________________________________________________________________
Address________________________________________
City_____________ State ____
Zip Code ____________
Phone: ________________________________
Email: ____________________________________________________
Please mark your availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9
AM
10
11
12
1
2
3
PM
4
5
6
7
Please list any hobbies, talents, skills, knowledge areas, educational background, etc. that you think might be helpful for ANC to know!
__________________________________________________________________________________________________________
Background Check Consent Form
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Allen Neighborhood Center
1611 E. Kalamazoo St. – Lansing, MI – 48912 – 517.999.3919
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