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: Do you plan on volunteering in-person or virtually? * In-Person Virtually Check all that apply. If necessary for your volunteer role, what licenses do you hold and would like to use? (Please include your license number for verification purposes.) Availability When are you available to volunteer? * Monday - Day Monday - Night Tuesday - Day Tuesday - Night Wednesday - Day Wednesday - Night Thursday - Day Thursday - Night Friday - Day Friday - Night Saturday - Day Saturday - Night Sunday - Day Sunday - Night 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: Have you received both doses of the Pfizer or Moderna COVID-19 vaccinations, or one dose of the J&J vaccination, and can you provide proof of vaccination prior to volunteering in-person? * Yes No 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!
