Name: *

Date: *

Address: *

City: *

State: *

Zip Code: *

Phone (Home):*

Phone (Office):

(Fax):

Email: *

A. Skills and Interests

1. Current Occupation:

2. Work Schedule:

3. Hobbies:

4. Previous Volunteer Experience:

5. Skills:

6. Interests (Check all that apply):

Working with Families
Working with Senior Citizens
Working with Children
Fundraising
Computer Skills
Grant Writing
Clerical/Office Work
Working Independently
Finances
Other

B. Preferences in Volunteering

Is there a particular group with which you are most interested in working?:

Children
Teens
Adults
Seniors

Are there any groups with which you would not be interested in working?:

No
Yes

What Groups?:

At what times are you interested
in volunteering?:

Flexible
Weekdays
Evenings

C. Availability

Would you prefer to volunteer in:

Washington
Greene County
Doesn't Matter

Do you have access to an automobile you can use for volunteer work?:

Yes
No

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