Volunteer Application

Minimum of 20 hours required in a 6 month period. Entire Application must be completed.

Program*

Adult
College
Teen (age 16 and up)

Name*

First	Middle	Last

Gender*

Male
Female

Date of Birth*

Home Phone

Cell Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email

Have you ever been an employee, intern or volunteer at Well Spring?*

Yes
No

If yes, please list dates.

School

Please provide the following information, if currently attending school.

School Name (If Currently Attending)

School Phone

School Address

Street Address Address Line 2 City State ZIP Code

Teen/College Volunteer

School Major/Concentration

Are you volunteering to meet a school requirement?

Yes
No

How many hours of volunteer work are you required to finish?

When do your volunteer hours have to be completed by?

Emergency Contact

In Case of Emergency Notify*

First Last

Emergency Contact Phone*

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Relationship*

Service Area Preferred

Service Area Preferred*

Please select one.

Availability

Days Available*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Times Available*

Earliest Date Available*

Additional Information

Previous Volunteer Experience*

If you are working with a special program for credit (club, etc.), please list:

Address of Special Program

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Have you ever been convicted of any criminal offense other than a minor traffic violation?*

Yes
No

If yes, please explain

Hobbies, Skills, Special Interest

Why do you want to be a Volunteer? (Career goals, etc.)

References

List

Name	Phone	How does this person know you?

Believing that the organization has a need of my services as a volunteer, I will:*

Be punctual and conscientious in the fulfillment of my duties and accept supervision graciously.
Conduct myself with dignity, courtesy and consideration.
Consider as confidential all information which I may hear, directly or indirectly, concerning a resident, doctor, or any member of personnel, and will not seek information in regard to a resident.
Take my problems, criticisms or suggestions to my supervisor.
Endeavor to make my work of the highest quality.
Uphold the Mission Statement and Core Values of this organization.
I hereby certify that the answers on this application are true and correct and that any misrepresentations or omissions of facts or false information on my part will be grounds for dismissal as a volunteer.
Acceptance as a volunteer is contingent upon satisfactory references and verification of the information submitted on this application/background check. I therefore authorize Well Spring to make such investigations and inquiries deemed necessary in determining to accept me as a volunteer.
I give my permission for Human Resources to copy my records for release to me, upon my request. These records may be presented to me in person, by fax or by mail. This authorization does not expire.

Please check all boxes.

Volunteer Application