Homework House Volunteer/Tutor Application
Please fill out this form to submit an application to become a volunteer/tutor at Homework House
Cell Phone Number
Alternate Phone Number
(if different from your local address)
Alternate email address
Emergency Contact Name
Emergency Contact Phone
(Skip if no longer in high school)
Year in High School
(Mark only one oval)
(Skip if you are not yet in college or are no longer in college)
Holyoke Community College
Mount Holyoke College
Year in College
I am (mark only one oval)
Previous Volunteer Experience
Special Skills or Interests
Days you are interested in volunteering
I'm not sure yet when I am available
If you are interested in volunteering on Fridays would you be interested in sharing a talent or skill with our students by running or helping to run a club?
In what grade are the students with whom you prefer to work?
Kindergarten to 3rd grade
4th to 6th grade
Can you commit to a regular schedule for
Fall ( September to December
Winter (December through January)
Spring ( February to May)
I'm not sure how long I can commit
By signing this application, I hereby give permission for use of my name, photo and likeness, to be used perpetually by Homework House INC or its representatives in Homework House INC's newsletters, website, for special events,official social media sites (including but not limited to Facebook, Youtube, Twitter and Instagram), recruitment materials or in the media without compensation. I hereby release Homework House INC from any claims arising out of my appearence.
Do you have any health limitations that might affect your ability to perform certain volunteer duties, or that the administrative director or site supervisor should be aware of? If yes, please explain briefly in the next field.
If you answered yes above, please explain briefly
Confidentiality of Information
In order to serve students effectively, all volunteers of Homework House must maintain strict confidentiality with respect to information about students, including names, addresses, and phone numbers. Please do not discuss any information about a student, except with appropriate personnel within the agency. Breach of confidentiality is a violation of the law, which can lead to civil liability and a fine. It is also a violation of ethical conduct. If in the course of your work you suspect a case of child abuse/neglect, please report this to the administrative director and site personnel. Staff and volunteers are mandated to report on such cases to the proper authorities
I certify that the statements made in this volunteer application are true and correct and have been given voluntarily. I further certify that I have read and understand the legal disclosure and confidentiality statement above. Please enter your full name below to certify.
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