Volunteer Application Volunteer Application Personal Information Name * Name First First Last Last Street Address * Address Line 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Name * Name First First Last Last Relationship * Street Address Address Line 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code 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 If you are human, leave this field blank. Submit 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? Phone Email 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
