Volunteer Application (Page 2 of 5) in pdf

PERSONAL REFERENCES

List 3 references (1 of each: employer or business, community and personal reference) who are not related to you:

Name: _________________________________ Phone:___________________ Email ___________________

Address: _______________________________ City-State Zip: _______________________________________

Name: _________________________________ Phone:___________________ Email ___________________

Address: _______________________________ City-State Zip: _______________________________________

Name: _________________________________ Phone:___________________ Email ___________________

Address: _______________________________ City-State Zip: _______________________________________

EMERGENCY INFORMATION

IN CASE OF EMERGENCY PLEASE NOTIFY:

Name: ________________________________ Ph: (H) _________________ Ph: (W) ____________________

Address: ___________________________________________________________________________________

Doctor: _______________________________ Phone: ___________________

Address: ___________________________________________________________________________________

Preferred Hospital: ___________________________________________________________________________

Medical Insurance Coverage/Carrier: ____________________________________________________________

Medical Insurance ID/Group Number: ___________________________________________________________

Please list any medical information that would aid us in case of emergency (For example: bee sting allergy,

epilepsy, drug allergy, medical alert bracelet.) _______________________________________________

VOLUNTEER PLACEMENT

Date Approved _____________ School/Program ___________________________________________________

Immediate Supervisor __________________________________________ Phone: _______________________

Volunteer placed as ___________________________________________________________________________

Volunteer Coordinator’s Signature ____________________________________ Date _____________________

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Volunteer Application Page 2