Volunteer Application for Heart-to-Heart
Today's Date *
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Contact Information
*Must be 18 years of age or older to volunteer, teens 15-17 must accompanied by an adult.
Name *
First and last name
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Primary Contact # *
Your answer
Alternate Phone
Your answer
E-Mail Address
Your answer
Availability
During which hours are you available for volunteer assignments? *
Required
Employment Information
I am: *
Employer or School Name
Your answer
Occupation or Major
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Phone Number
Your answer
Interests
Tell us in which areas you are interested in volunteering:
How did you find out about our volunteer program?
Why would you like to volunteer with Heart-to-Heart? *
Your answer
Special Skills or Qualificatoins
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or though other activities, including hobbies or sports. *
Your answer
What other volunteer work have you done? When? What organizations?
Your answer
Are you fluent in a language other than English? If so, what language(s)?
Your answer
Person to Notify in Case of Emergency
Name *
Your answer
Relationship *
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Primary Phone # *
Your answer
Alternate Phone #
Your answer
E-mail Address
Your answer
References
Please list two people other than relatives who would be willing to seve as personal references
Reference #1
Name *
Your answer
Relationship *
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Primary Contact # *
Your answer
Alternative Phone #
Your answer
E-Mail Address
Your answer
Reference #2
Name *
Your answer
Relationship *
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Primary Phone # *
Your answer
Alternative Phone #
Your answer
E-mail Address
Your answer
Agreement and Signature
By submitting this application, I affirm that the facts set forth in it 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 Heart-to-Heart 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 Heart-to-Heart 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 Heart-to-Heart families it serves.

*
Required
Please Print Name Below: (for use as signature) * *
Your answer
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

It is also our policy to provide a safe environment for the people whom we serve. Certain volunteer positions require the applicant to provide a copy of immunization records from a health care provider including a TB test results.

Thank you for completing this application form and for your interest in volunteering with us.

Please fill out this form and email it to h2hincinfo@gmail.com with the subject: Volunteer Application: your name

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