Volunteer Application Form Today's Date * Name * First Last Date of Birth * Address * City/State/Zip * Phone (Cell) * Phone (Home) Email Address * Emergency Contact (First & Last Name of Person) * Emergency Contact Phone Number * Skills/Interests Educational and Professional Background * Current Job * Hobbies, Skills, Interests * Volunteer Preferences (Check all that apply) * House Host/Hostess Reiki, Massage, Yoga, Other Practitioner Leading Art/Other Projects Research, Training, or Special Projects Fundraising/Special Events Community Outreach Grant Writing Public Speaking, Fundraising, etc. House Maintenance/Facilities Virtual Support with Computer Access Virtual Support with Phone Access Other If you selected other, please explain your volunteer preferences: Availability When are you available to volunteer? * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Prefer to work on specific event If you selected a specific event, please put the name of the event: Background Verification 1. Have you ever been convicted of a criminal offense? * Yes No 2. Have you ever been charged with neglect, abuse, or assault? * Yes No 3. Do you use illegal drugs? * Yes No 4. If you have any physical limitations which might limit your ability to perform certain jobs, please specify: Non-Family References Please list two non-family references that we may contact. 5. Name of Reference 1 * First Last Phone Number of Reference 1: * Address of Reference 1: * 6. Name of Reference 2 * First Last Phone Number of Reference 2: * Address of Reference 2: * How did you hear about Wellness House of Annapolis? Check all that apply. * Print Advertisement Radio/TV Anne Arundel County Volunteer Center Another Agency School Friend Other If you selected other, please let us know where you heard about us! Signature of Applicant I certify that the information in this application is true and correct to the best of my knowledge. I understand that false information given on this application is sufficient for my dismissal. Additionally, I understand that this organization may perform a criminal background check and make inquiries into my educational and occupational history. Finally, I understand that during the recruitment process the organization may contact the references I have listed. Signature of Applicant * Date * Signature of Parent (if Applicant is under the age of 18) Date Thank you for supporting Wellness House of Annapolis!
