Impact Reading Center Volunteer Application
Today's Date *
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First Name *
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Last Name *
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Gender
Last Four of SSN: *
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Work Phone
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Cell Phone *
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Email Address *
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Address *
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Birth date *
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Employment Status *
If student, please list a permanent address
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If employed, please list employer name and address
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Marital Status
In Emergency, notify (Please include phone number and relationship): *
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How did you hear about City Impact? *
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Why do you wish to volunteer at City Impact? *
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Have you volunteer/served with City Impact previously? If yes, please specify in what capacity. *
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Describe any skills/experience/talents you bring to this volunteer position. *
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Do you speak any other languages? Please specify and provide level of fluency.
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What other types of ministry/volunteer opportunities/community groups have you been involved in? *
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What is your highest level of education completed? *
Area/field of degrees received/courses taken:
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Is it necessary for you to limit your physical activity? *
Are you licensed to practice a profession? *
Have you received professional help for a nervous, mental, or emotional disorder? *
Do you have a police record? *
Do you now or have you ever used narcotics, hallucinogens, drugs not prescribed by a physician? *
Have you been involved in any incidents of child abuse, sexual or other? *
If you marked yes to any of the above, please explain (Otherwise write N/A): *
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