Volunteer Opportunity

Location

Today's Date

Name

Email

Address

City

State

Zip

Home Phone

Cell

Are you 18 years of age or older?

yes no

Current Employer

Current Position

Work Phone

May we contact you at work?

yes no

How did you learn about KCSL?

What other volunteer opportunities interest you?

Childcare

Phone Counselor

Special Events

Group Facilitator

Office Work

Development

Other

Previous Volunteer Experience

Skills and Experience that would be applicable to your volunteer job	Administration	Data Entry	Driver	Handyman	Medical	Other
	Social Service	Translator/Language		Licensed? License Type/#

What are your reasons for volunteering?

What length of time are you looking to volunteer for the Agency?

6 months or more

6 months or fewer

Special Event

Have you been convicted of a crime?

yes no

Please Explain:

In case of an emergency, whom may we contact?
Name		Relationship		Phone
Physician		Phone		Preferred Hospital

Please list for references (please, no relatives), Complete ALL information requested. Please type or print.

Name	Address	City	State	Zip	Phone

Signature

Date

Any contributions to the cost of performing required background screens are appreciated.