Your Contact
Information
* First
Name:
* Last
Name:
* Street
Address:
Street
Address (cont'd.):
* City:
* State:
* Zip:
* Email Address:
* Day Phone Number:
(517xxxxxxx)
Night Phone Number:
(517xxxxxxx)
Business Address:
Business Address (cont'd.):
Business City:
Business State:
Business Zip:
Your Personal
Information
* Date of Birth:
/
/
(month, day, year)
Example: 05/25/1935
Your Prior
Employment Experience
Employer #1: Occupation/Title:
Employer #1: Employer:
Employer #1: Years of Experience:
- Choose One -
0-1 year
1-3 years
3-5 years
5-10 years
More than 10 years
Employer #2: Occupation/Title:
Employer #2: Employer:
Employer #2: Years of Experience:
- Choose One -
0-1 year
1-3 years
3-5 years
5-10 years
More than 10 years
Your Prior Volunteer
Experience
Organization:
Activity/Job Title:
Date or Year of Service:
Organization:
Activity/Job Title:
Date or Year of Service:
More About Your
Experience
List any hobbies or interests that
might be helpful with your volunteer work.
Can you read, write or speak fluently a
language other than English?
- Choose One -
Yes
No
If yes, please list languages and
whether you can read, write, or speak it fluently:
Your Availability
Please list days and times that you are
available to volunteer.
Check the days that you are available and then select the times
(a.m. or p.m.) for each day.
Yes/No
# of
hours
Day
Start
Time
A.M. or
P.M.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Mon.
a.m.
p.m.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Tue.
a.m.
p.m.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Wed.
a.m.
p.m.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Thurs.
a.m.
p.m.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Fri.
a.m.
p.m.
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
Sat.
a.m.
p.m.
Volunteer Interests
Please choose the type (or types) of
volunteer work that interests you:
Building Security Attendant
Clerical Work/Typing
Computer Donor Program
Computer Data Input/Data Entry
Correspondence
Equipment Repair/Maintenance
Fund Raising
Gardening
Gift Buying (Christmas)
Helping Friends Together
Library Cataloguing
Mailing
MIS Disability Transport
One-on-One Activities
Planning Committee
Seasonal Decorations
Sewing/Mending
Snow Removal
Teach a craft
Telephoning
Volunteer Meetings
- Choose One -
Monthly
Quarterly
As a volunteer, I am willing to meet
with other volunteers...
Volunteer Agreement
- Choose One -
Yes
*I do hereby certify that the above
information is accurate. I will abide to all State and Federal
laws when representing disAbility Connections, Inc.
- Choose One -
Yes
*As a volunteer who gives time and effort in these activities, I am
willing to have my picture appear in newspapers, magazines or on
file which relates to disAbility Connections' volunteers.
Optional Information
Request
I would like to request additional information
regarding the following topic(s):
Planned Giving Program
Computer Donation Program
Volunteer Opportunities
Newsletter Subscription
