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Date
/
Month
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Day
Year
Date
Applicant/Company Representative Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Email
*
example@example.com
Gender
Date of Birth
*
/
Month
/
Day
Year
Date
Race
Organization you represent (If applicable)
Are you a citizen of the United States?
*
If no, are you authorized to work in the U.S.?
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
*
If yes, please explain
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Experience
Please tell us about any relevant volunteer interests/skills:
*
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Availability
How many hours would you like to volunteer each week/month?
What day(s) are you available to volunteer? Please check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
What hours are you available to volunteer?
Is there a specific program in which you would like to volunteer?
Please Select
Adult Day Services
Assistive Technology Services
Children's Services
Family Forward
Hart Gallery
The Speech & Hearing Center
Summer Camp
Signal Centers Admin
Work Ready
Wherever there is a need
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Emergency Contact Information
Please add two emergency contacts.
Contact 1 Name
*
Address
Work Phone
Mobile Phone
Relationship to applicant
Contact 2 Name
*
Address
Work Phone
Mobile Phone
Relationship to applicant
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References
Please add the contact information for two references (personal or professional) and we will send them Statement of Reference forms to fill out. We recommend following up with your contacts to ensure they received and have filled out the form as you will not be able to fulfill your volunteer placement without completed references.
Name
First Name
Last Name
Email
example@example.com
Name
First Name
Last Name
Email
example@example.com
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Video Training
If you are interested in volunteering with Adult Day Services or Children's Services, please watch these mandatory training videos and sign the acknowledgement form below.
Volunteering with Adult Day Services
Volunteering with Children's Services
If you use a screen reader and are the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of Applicant
Date
/
Month
/
Day
Year
Date
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Notification/Authorization for Procurement of Consumer Reports
This acknowledgement allows Signal Centers to perform a Background Check on the volunteer applicant.
Driver's License State (e.g. GA, TN)
*
Driver's License Number
*
Social Security Number
*
Please list every city and state in which you have lived in the last seven years.
*
City, State
City, State
City, State
City, State
City, State
City, State
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Volunteer Handbook Receipt Acknowledgement
Signal Centers Volunteer Handbook
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Disclaimers, Agreements, and Consent Forms
Please review each section carefully.
If you use a screen reader and are the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of Applicant
Date
/
Month
/
Day
Year
Date
If you use a screen reader and are the parent/guardian of the applicant, please type your name in the field below as your signature. Otherwise, leave blank and complete the Signature section below.
Signature of parent/guardian (If applicant is under 18)
Date
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Month
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Day
Year
Date
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