Dr Barbara Seniors Harkins Foundation
Volunteer Application
Contact Information
Name: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
ZIP Code: *
Your answer
Home Telephone:
Your answer
Work Telephone:
Your answer
Cell:
Your answer
May you be called at work?
How long have you lived in Dade or Los Angeles County?
Your answer
Do you drive?
Do you have an automobile available to you?
Your Education
High School:
(Select highest completed)
College:
(Select highest completed)
Graduate:
(Select highest completed)
Major:
Your answer
Degree:
Your answer
Work/Volunteer History
Name and Address of present or last employer or volunteer project:
Your answer
Start date:
(You can enter 1 for the day if exact start date is not known)
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End date:
(You can enter 1 for the day if exact start date is not known)
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Supervisor's Name:
Your answer
Brief description of work:
Your answer
List your other current community activities and membership in clubs, church, other organizations:
Your answer
Languages spoken:
Your answer
Hobbies/Special Interests:
Your answer
When would you be available for volunteer service?
(Select days of the week and times of day)
Approximately how much time can you contribute weekly as a BSH volunteer?
Your answer
Do you have any training or experience in any of the following?
(Please select all that apply)
If you selected any items above, please describe your training or experience:
Your answer
Have you ever been arrested for a crime?
If yes, what charge?
Your answer
Date of arrest/disposition:
(You can enter 1 for the day if exact date is not known)
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Where did this occur?
Your answer
How did you learn about the BSH Volunteer program?
Your answer
Please include a brief statement explaining why you want to volunteer with our organization:
Your answer
Personal Reference #1
Name:
Your answer
Address:
(Street, City, State, ZIP Code)
Your answer
Telephone number:
Your answer
Relationship:
Your answer
Personal Reference #2
Name:
Your answer
Address:
(Street, City, State, ZIP Code)
Your answer
Telephone number:
Your answer
Relationship:
Your answer
In Case of Emergency Contact
Name:
Your answer
Relationship:
Your answer
Telephone number:
Your answer
Affirmation and Release
I hereby affirm that all of the answers provided on my Volunteer Application are true. *
Please enter your name below to accept this statement.
Your answer
I hereby authorize the Dr Barbara Seniors Harkins Foundation to investigate my background to determine my fitness as a potential volunteer. *
Please check the box below to authorize this statement.
I understand that the information requested in this application will be used only for the purpose of determining suitability as a volunteer. *
Please check the box below to authorize this statement.
Please type your name in the box below as your electronic signature for this application form. *
Your answer
Please select today's date as your date of electronic signature. *
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