TODAY’S DATE:Name:Date of birth: Home Phone: Cell Phone:Current address:City: State: ZIP Code:Email:Employer’s Name/School’s Name:Education/Special Training:Occupation/Academic Major:Language(s) Spoken:

Agency: ____________________________________________________________________________________________________Dates of service:_____________________________________________________________________________________________Number of service hours:______________________________________________________________________________________

Please list any special talents you may have, such as painting, clerical skills, phone calling, gardening, etc:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Placement Preferences: Please indicate 1st, 2nd, and 3rd choice.______ 1. Special Events Volunteer______ 2. Peace For Kids Child Development Center Volunteer ______ 3. Family Program Volunteer______ 4. Our Lady of Perpetual Help Volunteer______ 5. St. Philippine Home Volunteer______ 6. Maintenance/Grounds Volunteer______ 7. Clothing/Donation Closet Volunteer______ 8. Other: ____________________________________________________________________________________________

Why would you like to volunteer at Queen of Peace Center?______________________________________________________________________________________________________________________________________________________________________________________________________________________

What would you like to get out of your volunteer experience at Queen of Peace Center?______________________________________________________________________________________________________________________________________________________________________________________

Duration of Volunteer Services:

One Time: _____ 1-3 months: _____ More than 3 months: _____ On-call:_____

Other: _________________________ to __________________________

Available Start Date: ______________________________ Proposed End Date: _______________________________

REFERENCES: Please list two people who would be willing to serve as personal references.

1. Name: ___________________________________________ Phone Number: ____________________________________

Street Address: _________________________________________ City:_______________________ State: ___________

Email Address: _______________________________________________

2. Name: ___________________________________________ Phone Number: ____________________________________

Street Address: _________________________________________ City:_______________________ State: ___________

Email Address: _______________________________________________

EMERGENCY CONTACT: In the event of an emergency, please list the person you would want notified.

Name: ___________________________________________ Phone Number: ____________________________________

Street Address: _________________________________________ City:_______________________ State: ___________

Email Address: _______________________________________________ Relationship: ____________________________________

Statement of Understanding:

I certify that all information is true and has been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest. I release the agency from any liability whatsoever for supplying such information.

I understand that I must be at least 18 years of age to volunteer at Queen of Peace Center.

Upon being offered a volunteer position, I understand that I may be required to provide additional information pertinent to the position for which applied.

SIGNATURESSignature of applicant: Date:Printed name of applicant: Date: