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Volunteer Service Application

2. APPLICANT INFORMATION

4. Last Name*

5. First Name*

7. Middle Name*

8. Date of Birth*
   Date of Birth

10. Email Address*

12. Street Address*

14. City*

15. State*

16. Zip Code*

18. Phone Number*

19. Work Phone Number

21. Area(s) of Interest*

23. Date You Can Start*
    Date You Can Start

24. Days Available*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday

25. Hours Available
    Hours Available Start Time

    —

    Hours Available End Time

27. EDUCATION

29. Name of School 1

30. School 1 Years Attended

32. School 1 Highest Level Completed

33. School 1 Subject Studied

35. Name of School 2

36. School 2 Years Attended

38. School 2 Highest Level Completed

39. School 2 Subject Studied

41. Please Attach Your Resume

43. VOLUNTEER EXPERIENCE

45. Have you ever volunteered before for Kent City Health Department?

    1. YES
    2. NO

47. Other skills or training (fluency in language,word processing skills, etc.)

49. MOST RECENT EMPLOYER

51. Recent Employer- Position Held*

53. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date

55. Recent Employer Name*

56. Recent Employer Phone Number*

58. Recent Employer Street Address

60. Recent Employer City

61. Recent Employer State

62. Recent Employer Zip Code

64. May We Contact Them?*

    1. YES
    2. NO

66. PROFESSIONAL REFERENCES
    (Minimum of Two)

    (Minimum of Two)

68. Reference 1 First Name

69. Reference 1 Last Name

70. Reference 1 Phone Number

72. Reference 2 First Name

73. Reference 2 Last Name

74. Reference 2 Phone Number

76. EMERGENCY CONTACT PERSON IN CASE OF EMERGENCY

78. Emergency Contact First Name

79. Emergency Contact Last Name

80. Emergency Contact Relationship

82. Emergency Contact Phone Number

84. Have you ever been convicted or plead guilty in court (even if you did not have a trial) of anything other than a misdemeanor or minor traffic violation?*

    1. YES
    2. NO

86. If yes, please explain:

88. AUTHORIZATION

90. ELECTRONIC SIGNATURE OF APPLICANT*

    Your electronic signature indicates that the facts contained in this application are true and complete to the best of your knowledge. False statements on this application shall be grounds for dismissal from the volunteer program. You authorize approval to check references. The organization is not obligated to provide a volunteer placement, nor are you obligated to accept it. Your electronic signature also indicates that you are volunteering for humanitarian purposes to benefit the public good and without compensation.

91. Date Signed*
    Date Signed

Leave This Blank:


93. Submit

* indicates a required field