Volunteer Application Name Personal Information First Name * Last Name * Street Address * Address Line 2 City * ZIP / Postal Code * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== 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 Contact Number * Alternate Contact Number Email Address * Date 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 First Name * Relationship Last Name * Street Address Address Line 2 City ZIP / Postal Code State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== 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 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 Games / Computer Outings Lunch Walks 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 Arranging Sports Web Design Carpentry Artistic Ability Other Better Care Starts Here For Questions or More Information Or Call: (804) 746-0743 Your Full Name Phone Number Email Address How Should We Contact You? How Should We Contact You?PhoneEmail Comment / Question 3 + 8 = Submit Independence for Adults in Need Exceptional Day Support, Adult Day Healthcare, Advocacy and Education info@hanoveradultcenter.com 7231 Stonewall Parkway Mechanicsville, VA 23111 (804) 746-0743 Our History
