Volunteer Application

Personal Information:

Name: ______

Address: ______

______

Phone: (Home): ______(Cell): ______(Work): ______

Email: ______

Retired? ______Congregation (optional): ______

How did you hear about the Shepherd's Center of Oakton-Vienna? ______

______

Volunteer Interests (check all that apply):

____ medical driver ____ office phone assistance ____ fundraising

____ companion driver ____ office computer assistance ____ publicity

____ friendly caller ____ mailings ____ grant writing

____ friendly visitor ____ web site maintenance ____ luncheon planning

____ handy helper ____ board membership ____ trip planning

____ decluttering ____ health and wellness ____ education planning

____ computer assistance ____ respite care ____ instructor

for seniors ____ special events ____ other

Availability Preference: Please check all that apply.

TIME/DAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY
MORNING
AFTERNOON

I can volunteer: ___ once a week ___ more than once a week ___ as needed

____ other: ______

Matching Information:

General interests, skills, volunteer experience, languages, and hobbies:______
Screening Information:

Have you ever been convicted for violation of any laws, traffic or otherwise? ____ yes ____ no

If yes, please explain: ______

Please note a criminal record check will be done for prospective volunteers who will work directly with our clients.

Do you have any physical condition that may limit your volunteer activities? ____ yes ____ no

If yes, please describe: ______

For Driver Volunteers Only: Do you have a valid driver’s license? ____ yes ____ no

License number: ______Expiration Date______

Insurance Company: ______Policy Number: ______

Expiration Date: ______

Emergency Contact:

Name:______Phone:______Relation:______

References:

Please list two people we may contact who are not family members. (You may include employers, teachers, religious leaders, etc.)

Name:______Phone:______Relation:______

Address:______

Name:______Phone:______Relation:______

Address:______

I understand and agree that my volunteer service is at will, which means that it is for no specified period and may be terminated by me or Shepherd’s Center of Oakton-Vienna at any time without prior notice, for any reason. I understand that misrepresentation or omission of facts may result in rejection of this application or termination. I hereby give my consent for the Shepherd’s Center to contact my references and conduct a background check.

______

Signature of Applicant Date

Please mail completed form to:

Shepherd’s Center of Oakton-Vienna

541 Marshall Road, SW

Vienna VA 22180

For information call Volunteer Coordinator at 703-281-5086 or email

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