Volunteer Application

The information on this form will help us assign you to the most appropriate volunteer position. Thank you for completing it in full.

Red Indicates required fields

Personal Information

First Name:

Last Name:

Address:

Address 2:

City:

State:

(ex. IN)

Zip:

Home Phone:

(ex. 123-456-7890)

Work Phone:

(ex. 123-456-7890)

Email:

Email Confirm:

Emergency Contact Information

Person to contact:

Relationship to person:

Phone:

Doctor's Name:

Doctor's Phone:

Volunteer Information & History

Education Years Completed:

Current Occupation:

Special Skills, Training, Interersts or Hobbies:

Have you ever worked as a volunteer before?

If yes, please give details:

In what area of volunteer work are you most interested?

Specific days and times when you are available:

List any experience in a health care facility, hospital or related institution:

Reference Information

Do you know a Grace Village resident, employee or other volunteer?

If so, please list their name(s):

If the above reference information is blank, please list one person as a reference:

First Name:

Last Name:

Address:

Address 2:

City:

State:

(ex. IN)

Zip:

Phone:

(ex. 123-456-7890)

Please tell us a little about yourself, including information that would aid us in your volunteer placement: