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Volunteer Application

SECTION I

Volunteer Position Title:

Name:

Address:

City:

State:

Zip:

Phone:

E-mail:

SECTION II

Previous Volunteer Experience:

Occupation (Past occupation if retired):

Other Information that will help us make good match (such as education, general interest/hobbies):

Language Spoken:

SECTION III

Availabilty and Volunteer Assignment Preference
Please Check All that Are Applicable:
I Am Available:

Morning (Mon-Fri)

Weekends

One Time Only

Afternoon (Mon-Fri)

Once A Week

As Needed

Evening (Mon-Fri)

More than Once A Week

OTHER

I could serve more than One Person: Yes No

Interest: Please tell us which areas you are interested in volunteering. NOTE: you must select at least One(1) of these fields

Administration

Events

Programs

Fundraising

Deliveries

Social Media

Counseling

SECTION IV

Have you ever been convicted for Violation of Any Laws, Traffic or Otherwise? Yes No

If Yes, Please Explain:

Do you have any Physical Conditions that may limit your Activities? Yes No

If Yes, Describe:

Who to Notify In Case of an Emergency?

Telephone Number:

SECTION V[REFERENCE]

Please list three persons we may call who are NOT family, one of whom may be your religious or spiritual leader, teacher, employer or relationship other than personal friend.

Name:

Phone:

Address:

relationship:


Name:

Phone:

Address:

relationship:


Name:

Phone:

Address:

relationship:

Comments:

I hereby give my consent to contact my reference; to contact my employers, past and present; and to conduct a background check.

As a volunteer of Development Initiative for Community Impact (DICI), I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problems which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to recieve any monetary payment or reward.

Signature of Applicant:

Date: