Volunteer Application
Three Little Birds Perinatal & Palliative Care Advocacy & Support Center
Email address *
Today's Date
MM
/
DD
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YYYY
Contact Information
Name
Address
City, State and Zip
Home/Cell Phone
Work Phone
E-Mail Address
Availability
During which hours are you available for volunteer assignments? (may check more than one)
Employment Information
I am currently
Employer or School Name
Occupation or Major
Work/School Address
Interests
In what areas specifically are you interested in volunteering?
How did you find out about volunteering for TLB?
Special Skills or Professional Qualifications
Please list any special skills or qualifications you have that would be an asset when volunteering for our organization.
Emergency Contact
Name and Phone Number of Person to Notify in Case of An Emergency
References
Please list 2 people who do NOT live with you that would be willing to serve as personal references for you.
1) Name, relationship to you, phone number
2) Name, relationship to you, phone number
By agreeing below, I affirm that all the facts set forth in this application are true and complete, and have been given voluntarily. I have answered all of the questions to the best of my ability and I have not and will not withhold any information that would unfavorably affect my application to be a volunteer. I will update Three Little Birds if any information on this application changes or of other information that might affect my qualifications as a volunteer. I understand any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate rejection as an applicant to be a volunteer or my termination as a volunteer.I voluntarily give Three Little Birds the right to make an inquiry of my past experience and I agree to cooperate in such inquiries and release from all liability or responsibility all persons, companies, and corporations supplying such information.In addition, I agree that I will keep confidential all materials that I may read or learn about during my volunteer experience. I will only discuss this information with appropriate staff and never off Heart-to-Heart grounds. If I ever use any part of my experience in writing, I agree that a member of the staff must review it first in order to protect the confidentiality and legal rights Three Little Birds families it serves. *
Please Print Name Below: (for use as signature) *
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