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The Healing Place Volunteer Application
Please fill in all appropriate information.
Name
Address
How long?
City
State
Zip
TELEPHONE:
Previous Address
Employer
Phone
In case of emergency, contact
Phone
Education:
Choose highest grade completed
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh grade
Twelfth Grade
College Year 1
College Year 2
College Year 3
College Year 4
Graduate School Year 1
Graduate School Year 2
Graduate School Year 3
Graduate School Year 4
Major or degree completed/attempted
Skills:
Mark all that apply
Driver's license #
Chauffeur's license #
Sign language
Typing/Computer
Bilingual language
Other
Prior training, certifications, licenses, etc.
Prior volunteer experiences
What do you see as your strengths and weaknesses in terms of volunteering for The Healing Place?
Have you, or anyone close to you ever been sexually assaulted?
Yes
No
Have you, or anyone close to you ever been reported to the Department of Social Services or Law Enforcement as a suspect of sexual assault?
Yes
No
Have you ever been accused or convicted of a misdemeanor or felony?
Yes
No If Yes, explain
Preferred volunteer work
Education Volunteer
Fund Raising
Office Volunteer
On-Call Advocate
Public Speaking
Special Events
Availability:
How did you hear about us?
Friend
Newspaper Article
Speaker
Telephone Book
Other:
References
Name
Phone
Address
Name
Phone
Address
Due to the nature of our work, a criminal background check is done on all who represent, work, or volunteer for The Healing Place. Do we have your permission to do a routine check of your record?
Yes
The Healing Place Volunteer Program reserves the right to make any inquiries deemed appropriate as to the suitability of anyone responsible for this type of work. All information we receive is confidential.
Signature
Date
