| Background Information |
| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Telephone (day) |
|
| Telephone (evening) |
|
| Date of Birth |
|
| Social Security # |
|
|
| Emergency Contact Name |
|
| Emergency Contact Relationship |
|
| Emergency Contact Telephone |
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| Emergency Contact Cell Phone |
|
|
Have you ever been convicted of a crime?
Yes No |
| If yes, when? |
|
| Offense |
|
| (A criminal record does not constitute an automatic bar to volunteering and will be considered only as it related to the job in question) |
Have you ever been convicted of an offence which involved abusing, neglecting, or mistreating individuals?
Yes No |
| If yes, please explain |
|
|
PERSONAL OR PROFESSIONAL REFERENCES
(Please list three [3] – no relatives) |
| Reference 1 |
|
| Address |
|
| Relationship |
|
| How long known |
|
| Phone |
|
|
| Reference 2 |
|
| Address |
|
| Relationship |
|
| How long known |
|
| Phone |
|
|
| Reference 3 |
|
| Address |
|
| Relationship |
|
| How long known |
|
| Phone |
|
|
| VOLUNTEER EXPERIENCE |
Organization / Type of Work / Dates of Service
|
|
| VOLUNTEER PREFERENCES |
How did you first learn about the Volunteer Program at Felician Village?
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What times/days do you prefer to volunteer?
|
Briefly explain why you wish to volunteer at Felician Village and what you hope to gain from your experience.
|
Present or previous occupation:
|
Special skills or training:
|
Do you speak or read a foreign language?
Yes No |
Please specify:
|
|
VOLUNTEER HELP THAT IS NEEDED AT FELICIAN VILLAGE
(check what you would be interested in) |
Transporting
Gift Shop
Stuffing envelopes
Village Market and Cafe
One-on-one visits
Bistro
Assisting in group activities
Bingo
Helping with larger events
Receptionist
|
|
SKILLS / INTERESTS
(Limit to five [5] categories) |
Animals
Mechanical Skills
Antiques
Music
Art/Drawing
Outdoor Activities
Arts/Crafts
Photography
Cards & Games
Quilting
Carpentry Skills
Reading to Others
Cashier
Sewing
Cleaning
Singing |
Collectibles
Sports
Computers
Theater
Cooking/Baking
Woodworking
Dancing
Writing
Entertaining
Yard Work
Fundraising
Other
Gardening
Instructor
History
Knitting/Crocheting |
|
|
I, the undersigned verify that the information in this form is true and correct to the best of my knowledge. I also hold harmless Felician Village and employees from any and all liability resulting from any personal injury received during the course of my volunteer activities. Felician Village has my permission to use my name, quotes, or photo for publicity purposes. |
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