First Middle Last Name *

Address *

City State Zip *

Phone *

Emergency Contact: *

Relationship: *

Emergency Contact Phone Number: *

Are you related to any youth or adult served by D2S or D2S employee? If yes, list name(s). *

Have you spoken with someone about volunteering at D2S? If yes, list name(s). *

D2S has many volunteer opportunities that may interest you.(Please check one department) *

Please state any other information that would be helpful in determining a good volunteer placement for you (type of volunteer work, ages of youth you most identify with, etc.) *

What day(s) would you be interested in volunteering? *

What kind of time commitment are you willing to make? *

What languages do you speak fluently? *

Please provide the names, addresses, and phone number of three references (2 of which are professional). Do not leave any information blank. *

I authorize D.E.S.T.I.N.E.D. to Succeed, Inc. to investigate all statements in this application. I also authorize them to conduct a background check to include a criminal record check (if I am 18 or older) and reference check. I hereby acknowledge that I have read and understood the preceding statement. I understand that my picture/video may be taken for the media and/or public relations and allow these pictures to be used for media and/or public relations purposes unless I otherwise submit in writing to D2S. *