Connections of CC - Volunteer Form

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Have you been convicted of a criminal offense?

Have you been convicted of a criminal offense? Yes No
Please give date, location, and details
Areas Of Interest: Check All That Apply

Areas Of Interest: Check All That Apply Connect 2 Redirect Coach/Mentor to Homeless Women (1 year commitment desired) Connect 2 Enterprise Volunteer (Assisting with functions in online store) Social Media/Marketing Team Fundraising/Grant writing Team Awareness Volunteer/Speakers Bureau (attends events and /or assists with community presentations
Availability
When are you interested in volunteering?

When are you interested in volunteering? On a regular basis occasionally, as your schedule permits
What days and times are you interested in?
Do you need:

Do you need: Student Internship Hours Community Services Hours
Are the hours for University of:
Court Appointed: Number of Hours Needed
Please describe your educational background and work history
Other Volunteer Experiences
Place #1
Name Of Organization
Beginning Date Beginning Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Contact Name Contact Name First Last
Contact Number Contact Number - ### - ### ####
May We Contact?

May We Contact? Yes No
Place #2
Name Of Organization
Beginning Date Beginning Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Contact Name Contact Name First Last
Contact Number Contact Number - ### - ### ####
May We Contact?

May We Contact? Yes No
Place #3
Name Of Organization
Beginning Date Beginning Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Contact Name Contact Name First Last
Contact Number Contact Number - ### - ### ####
May We Contact?

May We Contact? Yes No
References
Reference #1
Name Name First Last
Relationship
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Reference #2
Name Name First Last
Relationship
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Reference #3
Name Name First Last
Relationship
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Are there any medical conditions that we should be aware of? (E.g. epilepsy, asthma, etc.)

Are there any medical conditions that we should be aware of? (E.g. epilepsy, asthma, etc.) Yes No
Please provide a brief explanation (include information on who we should contact is case a medical emergency occurs at Connections):
Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
Thank you for your interest in volunteering with Connections of Cumberland County

Connections of CC - Volunteer Form

Availability

Other Volunteer Experiences

Place #1

Place #2

Place #3

References

Reference #1

Reference #2

Reference #3

Thank you for your interest in volunteering with Connections of Cumberland County