VOLUNTEER REGISTRATION FORM
Name _______________________________, _____________________ ________
(Last) (First) (MI)
Address_______________________________________________________________
(Street) (City, State and Zip)
Phone___________________________ Email ______________________________
Best time to be reached? ___________ Date of birth __________________________
· Skills and Interests: (Check all that apply)
__Transport People __Home Repairs __Budget Counseling
__Transport Furniture __eBay __Business Planning
__Run Errands __Mailings __Spanish Translation
__Visit Homebound __Typing, Data Entry __Clothing Cupboard
__Mentor a child __Clerical __Food Pantry(Mt. Morris)
__Mentor a Mom __Answer Phones __Board of Directors
__Childcare for support __Sewing/Crafts __Other:_________
group __Marketing
__Provide Respite Aid __Retail Management
· I prefer to work with: (Check all that apply)
__Infants __Children __Teens __Adults __Seniors __Any Age
__ I prefer behind the scenes work
· I prefer to volunteer in the geographical area(s) in Livingston County:
__Avon __Caledonia __Dansville __Geneseo __Lima __Livonia
__Mt. Morris __Nunda __Springwater __York __no preference
· I prefer to volunteer (per month): __< 2 hours __2 - 4 hours __> 4 hours
Other______________________________________________________________
· I prefer to volunteer in the: __mornings __afternoons __weekends __as needed
· Day(s) available: _______________________________________________________
· If driving, driver’s license #__________________ Expiration Date_______________
Insurance Provider_____________________________
· Have you ever been convicted of a felony or misdemeanor in any jurisdiction?
__Yes __No
If “Yes”, please list the specific nature and details of the crime(s), date(s), court location, sentencing information, and disposition of sentence on another sheet of paper.
· Are there any pending criminal charges filed against you? __Yes __No
If “yes” please specify: ____________________________________________________
In case of emergency, contact: (required)
Name______________________________ Relationship_______________________
Address_______________________________________________________________
Street City State Zip
Phone______________________________ Other phone____________________
(cellular, work, etc.)
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I certify that all statements made by me on this application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for on this application is cause for rejection of this application or for subsequent dismissal.
I hereby acknowledge that I have read the above statement and understand the same.
Signature of Registrant__________________________________ Date____________
It is the policy of Catholic Charities to foster equal volunteer opportunities and affirmative action for applications without regard to race, color, sex, religion, national origin, age or disability.
Please note that certain volunteer assignments will require the applicant to undergo background checks as a prerequisite. Your cooperation is appreciated.
Revised 10/01/09
Mail to:
Catholic Charities of Livingston County
34 East State Street
Mt. Morris, NY 14510