Volunteer Application Volunteer Application Personal Information Name * Name First First Last Last Street Address * Address Line 2 City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Primary Phone * Email Address * Alternate Phone Year of Birth * Do you have any physical limitations that should be taken into consideration when arranging volunteer assignments for you? * Yes No Education / Background Highest level of education completed: * Less than High School High School / GED Some College / Certificate Program College Graduate Graduate School I am currently: * Student Employed Not Employed Homemaker Retired Special Skills / Certifications Have you ever been convicted of a criminal offense other than minor traffic vioations? * Yes No Is your volunteer service required to fulfill a community service obligation? * Yes No Emergency Contact Information Emergency Contact Name * Emergency Contact Name First First Last Last Emergency Contact Relationship * Emergency Contact Street Address Emergency Contact Address Line 2 Emergency Contact City Emergency Contact State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Emergency Contact Zip Code Emergency Contact Phone * Volunteer Information Indicate the day(s) of the week and the time(s) of day you prefer: * I am able to commit to: * Regular, ongoing jobs (requires a 6 month commitment of at least 4 hours per month) Part time, ongoing jobs (requires a 3 month commitment of at least 2 hours per month) On call / Special assignments (no time commitment required, but placements are limited) If you are applying for a specific job or activity, please list it here: Programs with which you might be interested in providing assistance: (check all that apply) Arts / Crafts Painting / Drawing Gardening Pet Therapy Swimming Ball Toss Shopping Trips Reading 1:1 Visitation Library Coffee Hour Video Games / Computer Outings Lunch Walk Outdoors Office Assistant Cards / Games Cooking Letter Writing Other Do you have any special skills or hobbies you'd like to share with us? (check all that apply) Computer Knowledge Musical Instrument Graphic Design / Layout Creative Writing Office / Clerical Skills Storytelling / Humor Newsletter Editing Bead Work Reception Desk Sewing / Needlework Grant Writing Organizational Skills Retail Experience Bulk Mailings Photography Fishing Event Planning Singing Flower Arrangement Sports Web Design Carpentry Artistic Ability Other Submit If you are human, leave this field blank. Better Care Starts Here For Questions or More Information Or Call: (804) 746-0743 Contact Us Name * Phone * Email * Contact * How Should We Contact You?PhoneEmail Message * If you are human, leave this field blank. Submit Independence for Adults in Need Exceptional Day Support, Adult Day Healthcare, Advocacy and Education [email protected] 7231 Stonewall Parkway Mechanicsville, VA 23111 (804) 746-0743 Our History
