Address: ___________________________________________________________________

_________________________________________________________________________

Phone:Home:___________________

Work:_____________________

Ext:_______________

Email:______________________________________________________________________

Education (please check the highest form of education you have completed)

[ ] High School Graduate     
[ ] Undergraduate Degree                 [ ] Graduate Degree

School:____________________  School:____________________
Major:____________________    Major:_____________________

I am currently a student at:_______________________________________

Employment Information

Occupation:______________________________________________________
Employer's Name:_________________________________________________
Address:________________________________________________________

Do you have any medical conditions that would affect your ability to perform certain volunteer duties, or that Volunteers In Action should be aware of? (Yes / No) Please explain:

Do you have any felony convictions? (Yes / No) If yes, please explain:

Do you have a reliable vehicle?
Do you have a valid driver’s license?
Do you have liability insurance?

Please list any specific agencies about which you would like to receive volunteer information (if any):

Population (please indicate your preference, all that apply)

[ ] Adults  [ ] Any  [ ] Infants/Toddlers  [ ] School Age Youth  [ ] Teens
[ ] Animals  [ ] Developmentally Disabled  [ ] Preschool Children  [ ] Seniors  
[ ] Victims of Domestic Violence

I am interested in
[ ] participating in single day /special events  [ ] providing transportation to individuals
[ ] serving on a nonprofit board or committee  [ ] snow shoveling
[ ] moving/transporting goods (Occasionally, the VP receives requests from agencies for volunteers who have a truck and/or are willing to assist clients with moving personal belongings, picking up and/or delivering donations, etc.)

I want to volunteer because:

Please include any additional information you think would be helpful in obtaining volunteer placements.

Parental/Guardian Consent
If you are under 18 years of age, or have a legal guardian, you MUST have the release signed by your parent/guardian before we can consider you for volunteer opportunities.

As parent/guardian, I have read the release statement below and give permission for the applicant to consider and/or accept volunteer opportunities referred to him/her by the Hillsdale County United Way & Volunteers In Action.

Release
I certify that the statements made in this volunteer application are true and correct, and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release Hillsdale County United Way & Volunteers In Action from any liability whatsoever for supplying such information. Hillsdale County United Way & Volunteers In Action is released from any liability in referring me to an agency and any liability that may arise when working for such agency.